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INTRACRANIAL  TUMORS  AMONG  THE  INSANE, 


A  STUDY  OF  TWENTY-NINE  INTRACRANIAL  TUMORS 

FOUND  IN  SIXTEEN  HUNDRED  AND  FORTY-TWO 

AUTOPSIES  IN  CASES  OF  MENTAL  DISEASE, 


BY 


I.  W.  BLACKBURN,  M.  D., 

Pathologist  to  the  Government  Hospital  for  the  Insane,  Washington,  D.  C. 


ILLUSTRATED  BY  THIRTY  PLATES  AND  SIXTY-FIVE 
MICROSCOPICAL  DRAWINGS. 


WASHINGTON: 

GOVERNMENT   PRINTING   OFFICE. 
1903. 


LETTER  OF  SUBMITTAL. 


Government  Hospital  for  the  Insane, 

Washington,  D.  C,  April  7,  1903. 
Sir:  I  have  the  honor  to  transmit  herewith  a  special  report  of  the 
pathologist  of  this  hospital,  including  text,  plates,  and  photographs, 
as  contemplated  at  the  time  of  the  submission  of  the  annual  report  of 
the  Board  of  Visitors.  This  report  includes  a  synopsis  of  all  the  cases 
of  brain  tumors  developed  at  the  hospital  during  the  term  of  service 
of  the  present  pathologist,  and  will  be  of  great  interest  and  value  to 
neurologists  and  specialists  in  diseases  of  the  brain.  I  respectfully 
request  its  publication  in  the  interest  of  science  as  a  portion  of  the 
regular  report  from  this  hospital.  This  portion  was  deferred  at  the 
time  of  the  submission  of  the  annual  report  until  the  necessary  data 
could  be  procured  and  put  in  shape  for  publication. 
Very  respectfully, 

A.  B.  Richardson, 

Superintendent. 
The  Honorable  Secretary  of  the  Interior, 

Washington,  D.  C. 


Dear  Sir:  I  have  the  honor  to  submit  to  you  the  work  on  intra- 
cranial tumors  prepared  for  publication  by  your  permission  and  under 
your  direction. 

The  work  consists  of  a  compilation  of  the  reports  of  cases  of  intra- 
cranial growths  which  have  been  published  in  the  pathological  supple- 
ments to  the  annual  reports  of  the  hospital  during  my  term  of  service, 
with  the  addition  of  two  cases  of  brain  tumor  studied  during  the  past 
fiscal  year. 

Five  photographic  plates  and  11  microscopical  drawings  are  here- 
with submitted  for  reproduction  by  photo-engraving  process,  and  25 
half-tone  plates  and  reproductions  of  54  microscopical  illustrations  are 
in  the  possession  of  the  hospital  ready  to  convey  to  the  printer. 

Trusting  that  the  work  may  meet  with  your  approval,  and  with 
niany  thanks  for  your  support  and  assistance,  I  am, 
Very  respectfully, 

I.  W.  Blackburn,  M.  D., 

Pathologist. 
Dr.  A.  B.  Richardson, 

Superintendent  Government  Hospital  for  the  Insane. 


A  STUDY  OF  TWENTY-NINE  INTRACRANIAL  TUMORS,  FOUND  IN  SIX- 
TEEN HUNDRED  AND  FORTY-TWO  AUTOPSIES  IN  CASES  OF  MENTAL 
DISEASE,  

INTRODUCTION. 

In  this  study  of  intracranial  growths  the  subject  has  been  considered 
mainly  from  the  standpoint  of  morbid  anatomy  and  pathological  his- 
tology. Occurring  as  they  did  among  the  insane,  the  clinical  histories 
are  often  very  deficient.  In  some  cases  the  patients  were  greatly 
demented  on  admission  and  could  give  no  clear  subjective  symptoms; 
in  some,  the  symptoms  of  brain  tumor  were  obscured  by  predominating 
mental  manifestations,  and  in  others  the  growths  were  small  and  prob- 
ably gave  rise  to  no  physical  nor  mental  disturbances.  In  several 
cases  the  presence  of  intracranial  growth  was  recognized  by  the  char- 
acteristic symptoms,  but  in  these  cases  it  was  not  deemed  wise  to 
operate;  and  in  most  instances  it  was  found  that  either  the  size  of  the 
growth,  its  nature,  or  its  situation  would  have  precluded  an  operation, 
home  of  the  dural  growths  might  have  been  removed  if  the}^  had  been 
discovered  while  the  tumors  were  small  and  had  not  penetrated  and 
seriously  damaged  the  brain.  It  is  this  that  gives  interest  to  the  study 
of  several  of  these  small  growths,  otherwise  of  little  importance  to  the 
clinician.  Owing  to  the  slow  growth  of  these  tumors  and  that  they 
penetrate  the  brain  mechanically  a  certain  degree  of  tolerance  is 
attained  by  the  organ,  and  unfortunately  such  growths  may  reach  con- 
siderable size  before  their  presence  and  location  are  recognizable  by 
brain  symptoms.  These  tumors  are,  however,  by  all  means  the  most 
favorable  for  operation,  as  they  do  not  infiltrate  the  brain  substance, 
they  are  sharply  circumscribed,  easily  enucleated,  and  if  removed 
would  not  recur.  Of  the  twenty-eight  true  tumors  found,  seventeen 
may  be  regarded  as  belonging  to  this  class  of  growths  properly  called 
spindle-celled  endothelial  sarcomata,  usualty  of  the  dura  mater.  They 
originate  as  small  wart-like  growths  from  the  inner  surface  of  the 
dura  mater  and  when  favorably  situated  for  operation  ma}T  be  easily 
removed,  in  many  cases  with  safety  and  the  preservation  of  mental 
health. 

Other  growths  which  invade  the  brain  tissue  and  replace  its  ele- 
ments by  infiltration  such  as  the  ordinary  forms  of  sarcoma  and  the 
gliomata  can  only  be  removed  b}T  sacrifice  of  the  portion  of  the  brain 
involved,  and  such  operations  can  scarcely  be  regarded  as  either  safe 
or  promising.  For  this  reason  some  of  the  tumors  studied  could  not 
have  been  removed  even  if  surgical  interference  had  been  attempted. 
This  study  has,  for  the  reasons  given,  mainly  to  do  with  the  morbid 
anatom}^  and  histology  of  these  growths,  and  to  facilitate  the  descrip- 
tions 30  plates  and  65  microscopical  drawings  have  been  introduced 
to  illustrate  the  intracranial  tumors  and  the  morbid  growths  with  which 
they  were  in  several  instances  associated. 

The  microscopic  fields  selected  were  those  best  illustrating  the  gen- 
eral character  of  the  growth;  in  some  this  was  possible  in  a  single 
drawing;  in  others  several  illustrations  were  necessary  to  show  the 

5 


6  INTRODUCTION. 

modifications  of  the  tumor  structure.  In  the  cases  of  adenoma  of 
the  hypophysis,  drawings  of  the  normal  glands  were  given  for  com- 
parison with  the  tumor  tissue  and  several  fields  from  the  latter  were 
introduced  to  show  slight  variations  in  histology  in  different  parts. 

Especial  attention  has  been  paid  to  the  illustration  of  the  several 
varieties  of  endothelial  sarcomata,  and  the  drawings  and  cases  have 
been  arranged  to  show  the  origin  and  development  of  the  peculiarities 
of  structures  which  make  these  growths  so  interesting  and  so  complex. 

The  gliomata  have  been  represented  by  a  number  of  drawings  from 
typical  fields  and  from  some  of  the  modifications  of  structure  to  which 
these  complex  tumors  are  subject.  In  the  writer's  opinion  these 
growths  can  no  longer  be  regarded  as  simple  tissue  tumors.  Accord- 
ing to  the  recent  and  accepted  views  as  to  the  blastodermic  origin  of 
the  neuroglia,  we  have  in  this  tumor  tisue  ectodermic  elements  in 
the  glia  cells  and  fibrils,  and  mesodermic  derivatives  in  the  blood 
vessels  and  their  accompanying  fibrous  investments.  The  result  is  a 
compound  tissue  tumor  with  complex  interrelations  not  yet  fully 
investigated. 

The  ordinary  sarcomata  are  represented  by  a  single  tumor,  a  round- 
celled  sarcoma,  which  probably  originated  as  an  angio-sarcoma  of  the 
pia  mater;  and  on  the  border  line  between  the  gliomata  and  sarcomata 
may  be  placed  the  tumor  represented  by  tig.  53,  case  820.  This  tumor 
was  called  a  glio-sarcoma,  but  it  may  be  with  equal  propriety  regarded 
as  a  small-celled  glioma. 

The  specific  granulomata  are  represented  by  a  case  of  multiple 
tubercular  tumors  of  the  brain  and  extensive  deposits  in  the  lungs, 
vertebra?,  and  elsewhere.  Tubercular  disease  of  the  brain  and  men- 
inges has  been  infrequent  in  my  autopsies,  as  most  of  our  patients  are 
adults.  Gross  syphilitic  disease  of  the  central  nervous  system  is  also 
rare,  and  it  is  perhaps  worthy  of  remark  in  this  connection,  that  in 
over  1,700  autopsies,  1  have  never  found  any  syphilitic  growth  of  the 
brain  which  could  be  dignified  by  the  name  of  tumor  or  gumma. 

Three  growths  were  found  within  the  pituitary  fossa;  two  of  which 
involved  the  pituitary  body  and  one  occupied  the  fossa  and  greatly 
enlarged  it,  but  did  not  affect  the  gland.  In  none  of  these  cases  were 
there  any  evidences  of  acromegal}7.  Two  of  these  tumors  were  adeno- 
mata of  the  hypophysis,  and  the  nature  of  the  third  could  not  be  deter- 
mined on  account  of  degeneration.  The  more  rare  forms  of  intracranial 
growths  have  not  been  found  in  my  autopsies,  and  no  secondar}7  deposits 
have  occurred  in  the  brain  from  the  malignant  tumors  of  other  organs. 
In  several  cases  tumors  of  different  character  coexisted  with  growths 
of  the  brain  and  dura  mater,  and  in  one  instance  three  tumors  of  dif- 
ferent structure  were  found  in  the  same  subject. 

Osteomata  in  the  form  of  exostosis  of  the  inner  table  of  the  skull, 
and  small  irregular!}7  shaped,  flat  bone  masses,  usually  of  the  falx, 
have  been  quite  common.  The  possible  relation  of  these  growths  to 
inflammatory  diseases  and  to  congenital  errors  of  development  would 
exclude  them  from  the  true  neoplasmata. 

The  writer  wishes  here  to  express  his  thanks  to  his  professional 
friends  whose  appreciation  of  his  Avork  prompted  the  invitation  to 
publish  it  in  this  form;  and  to  Dr.  A.  B.  Richardson,  superintendent 
of  the  hospital,  for  his  encouragement  and  support,  without  which  the 
work  could  not  have  been  accomplished. 

Government  Hospital  for  the  Insane, 

December  31,  1902. 


PLATE  T. 


Case  853.    Tumor  of  brain.    Spindle-celled  sarcoma. 


H   -e 


PLATE  VII. 


Case  965.    Section  of  brain  showing  tumor  in  temporal  lobe. 


Case  1178.  Spindle-celled  sarcoma  of  the  brain.  The  plate  shows  a  transverse  section  through 
the  middle  of  the  tumor,  the  overlying  skull,  dura,  falx,  and  tentorium.  The  protuberance  of 
the  bone,  the  depression  in  the  surface  of  the  tumor,  and  the  invasion  of  the  brain  by  the 
tumor  are  shown  by  this  section,  a,  skull  bone;  6,  tumor;  c,  falx  cerebri;  <l,  dura  mater; 
e,  tentorium;  /,  thin  layer  of  brain  tissue  of  median  surface  of  hemisphere. 


PLATE  XI. 


Case  1178.    Diagram   showing  the  situation  of  the  tumor  and  the  place  of  section  shown  in 

Plate  X. 


PLATE  XIV. 


Case  1130.    Multiple  soft  fibromata  of  the  skin.    These  tumors  of  the  skin  coexisted  with  hemor- 
rhagic spindle-celled  sarcoma  of  the  cerebellum. 


PLATE  XVI. 


Case  1426.    Section  of  brain  showing  glioma  of  left  frontal  lobe,    a.  Portion  of  cyst  in  the  interior. 
The  dotted  line  indicates  the  apparent  boundary  of  the  tumor. 


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PLATE  XXVI. 


Case  991.    Tubercular  tumor  of  cerebellum. 


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Fig.  1.    Case  853.    Spindle-celled  sarcoma  of  brain,     x  300.     (Reduced  ±) 


Fig.  2.    Case  853.    Spindle-celled  sarcoma  of  brain,     x  300.     (Reduced  | 


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Fig.  3.    Case  842.    Spindle-celled  sarcoma  oJE  dura  mater,     x  300.    (Reduced  a.) 


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Fig.  4.    Case  774.    Spindle-celled  sarcoma  of  dura  mater,     x  300.    (Reduced  j.) 


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Fig.  5.  Case  1436.  Section  from,  spindle-celled  endothelial  sarcoma  of  dnra  mater,  showing  the 
general  structure  of  the  growth,  several  concentrically  arranged  cell  masses,  and  two  blood 
vessels  with  fibrous  walls  running  in  longitudinally  cut  cell-gronps.  The  fine  stippling  is  used 
for  shading;  the  cell  bodies  do  not  show  granulation  with  this  amplification.  x  300. 
(Reduced  \.) 


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Fig.  6.  Case  1436.  Spindle-celled  endothelial  sarcoma  of  dura  mater.  Section  from  the  junction 
of  the  growth  with  the  inner  layer  of  the  membrane,  showing  the  complete  union  of  the  two. 
At  the  surface  of  the  dura  the  tumor  was  usually  quite  vascular,     x  300.     (Reduced}.) 


Fig.  7.    Case  76.    Tumor  of  brain,  showing  one  large  and  three  small  hyaline  bodies.     X  300. 

(Reduced  a.) 


Fig.  8.    Case  76.    Tumor  of  brain,  showing  hyaline  globes  and  cell  nests,     x  300.     (Reduced}.) 


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Fig.  9.    Case  715.    Spindle-celled  sarcoma  of  the  falx  cerebri,     x  300.    (Reduced  ±.) 


Fig.  10.    Case  715.    Large  hyaline  globe  surrounded  by  many  layers  of  spindle  cells;  from  tumor 
Of  falx  cerebri,     x  300.     (Reduced  i.) 


Fig.  11.  Case  715.  Tumor  of  the  falx  cerebri,  enlarged  f:  (a)  tumor;  (b)  dura  mater;  (c)  superior 
longitudinal  sinus;  (d)  falx  cerebri,  which  may  be  traced  for  some  distance  through  the  tumor; 
(r)  inferior  longitudinal  sinus;  (/)  Pacchionian  body.  The  falx  is  bent  over  for  convenience  in 
sectioning. 


Fig.  12.  Case  114(3.  Degenerated  spindle-celled  sarcoma  of  the  dura  mater.  The  cellular  tissue 
has  become  fibrous  and  hyaline,  so  that  the  cells  and  nuclei  are  very  indistinct,  and  many  of 
the  concentrically  arranged  cell  masses  have  become  fibrous,  hyaline,  and  finally  calcified. 
The  almost  homogeneous  appearance  of  the  degenerated  tissue  has  been  represented  by  fine 
stippling,     x  300.     (Reduced  |.) 


Pig.  13.  Case  1146.  Soft  carcinoma  of  the  pyloric  end  of  the  stomach.  Some  of  the  cells  show  a 
tendency  to  columnar  shape  and  a  single  layer  arrangement  along  the  walls  of  the  alveoli, 
x  300.     (Reduced  |.) 


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Fig.  14.  Case  1146.  Section  showing  cancer-cell  nests  in  the  connective  tissue  trabecule  between 
the  muscular  bundles  of  the  middle  layer  of  the  stomach  wall.  The  small  cell  infiltration  of 
the  connective  tissue  is  seen  in  the  vicinity  of  the  cancerous  nodules.  The  muscular  bundles 
are  cut  transversely,     x  300.  (Reduced  a,) 


Fig.  15.  Case  1516.  Section  of  spindle-celled  endothelial  sarcoma  of  dura  mater,  showing  several 
hyaline  spherules  still  retaining  the  nuclei  of  cells,  and  hyaline  bands  in  the  midst  of  longi- 
tudinally cut  spindle  cells.  One  of  the  hyaline  rods  is  cut  transversely  at  one  end,  showing  an 
oval  outline,     x  300.    (Reduced  J.) 


Fig.  19. 


Fig-.  20. 


Figs.  16-20.    Case  1516.    Sections  from  spindle-celled  endothelial  sarcoma  of  dura  mater,  showing 

the  various  stages  in  the  hyaline  transformation  of  the  cell  spherules  into  hyaline  globes. 

Fig.  21  shows  the  peculiar  cell  grouping  which  would  develop  into  the  so-called  "  psammoma" 

of  some  pathologists,     x  300.     (Reduced  £.) 


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Fig.  212.    Case  965.    Spindle-celled  sarcoma  of  brain,  with  hyaline  degeneration  of  the 
trically  arranged  cell-groups.    Psammoma.     x  200.     (Reduced  i.) 


Fig.  23.    Case  965.    Low-power  view  of  spindle-celled  sarcoma,  or  psammosarcoma  of  brain, 
showing  the  numerous  hyaline  spherules  which  crowd  the  tissue,     x  50.     (Reduced  f ) 


WO*' 


Fig.  24.  Case  1503.  Endothelial  sarcoma  of  the  dura  mater.  Section  showing  the  general  struc- 
ture of  the  growth.  Many  cell  whorls  are  shown  separated  by  spindle-cell  bands,  and  with 
endothelioid  cells  in  the  central  portions.  Numerous  vessels  with  thick  hyaline  walls  are 
shown,  and  a  portion  of  a  very  large  hyaline  spherule,     x  2D0.     (Reduced  |.) 


Fig.  25.  Case  1503.  Endothelial  sarcoma  of  the  dura  mater.  The  drawing  shows  several  cell 
groups  separated  by  delicate  bands  of  spindle-cell  tissue,  giving  an  alveolar  appearance  to  the 
tissue.  The  central  cells  are  seen  to  be  round  and  endothelioid,  the  peripheral  layers  are  spin- 
dle shaped,  and  in  the  cell  bands  the  spindles  are  very  delicate  and  the  nuclei  elongated. 
Four  hyaline  spherules  and  two  thick-walled  vessels  are  shown  in  the  center  of  the  drawing. 
X  300.     (Reduced  i.) 


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Fig.  26.  Case  1582.  Section  showing  the  geneial  structure  of  the  spindle-celled  endothelial 
sarcoma  of  dura  mater.  A  number  of  hyaline  spherules  are  seen  and  cell  whorls  in  various  stag- 
es of  degeneration . 

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Fig.  29.  Case  1178.  Spindle-celled  sarcoma  of  the  dura  mater.  The  section  shows  the  general 
structure  of  the  tumor  and  one  of  the  bands  of  dense  connective  tissue  which  intersect  the 
tumor  in  every  direction.  The  whorl-like  arrangement  of  the  spindle  cells  is  seen  in  the  cen- 
ter of  the  drawing.  The  round  nuclei  are  chiefly  transverse  sections  of  the  spindle  cells,  x  300. 
(Reduced  \.) 


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Fig.  30.  Case  1178.  Spindle-celled  sarcoma  of  dura  mater.  The  section  shows  a  large  blood  ves- 
sel with  an  enormously  thickened  and  hyaline  wall,  and  two  small  vessels  almost  obliterated 
by  the  same  process.  Some  dense  connective  tissue  is  seen  in  the  vicinity  of  the  blood  vessels. 
X  300.     (Reduced  |. ) 


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Fig.  3J.  Case  1130.  Hemorrhagic  spindle-celled  sarcoma  of  cerebellum.  The  hemorrhagic  infil- 
tration is  shown  at  the  lower  part  of  the  drawing.  A  small  artery  with  thickened  hyaline 
walls,  and  one  totally  obliterated  by  the  same  process,  are  shown  in  the  section.  S00. 

(Reduced  f.) 


Fig.  33.    Case  1130.    Soft  fibroma  of  the  skin.    The  field  shows  a  transverse  section  of  a  small 
artery  and  an  optical  longitudinal  section  of  a  minute  vein,     x  300.     (Reduced  £.) 


portion  of  one  of  the  tumors  •> 

and  less  numerous  than  in  fig.  33.     x  300.     (Reduced  i.) 


Fig.  35.    Case  833.    Endothelial  sarcoma  of  dura  mater,     x  300.    (Reduced  a.) 


mm  w;?^m^^ 


Fig.  36.     Case  S33.     Adenoid  cancer  of 
stomach,     x  200.    (Reduced  a.) 


Fig.  37.    Case  833.    Small  round-celled  sarcoma  of  testicle. 
X  300.     (Reduced  |.l 


Fig.  38.    Case  539.    Endothelial  sarcoma  of  dura  mater,     x  300.     (Reduced}.) 


m 


fflt*  * 


ry  - 


.y  ^ 


Fig.  39.  Case  27S.  Endothelial  spindle-celled  sarcoma  of  the  dura  mater.  Field  showing 
the  general  structure  of  the  cellular  portions.  The  oval  nuclei  belong  to  spindle  cells  with  nar- 
row cell-bodies  closely  applied  to  each  other;  the  round  nuclei  probably  are  transverse  sec- 
tions of  the  same  cells,  though  round  cells  apparently  exist  in   groups   in    some  parts  of  the 

growth. 

X  300      (Reduced  l4). 


i 


■§3  a'**  .■-■.- 


®  J?®61©*     ®'  ®  '     ■  W         ~im 


',    J 


b"ig.  40.  Case  27S.  Section  of  the  same  tumor  represented  in  Fijj .  39.  showing  the  tendency 
of  some  of  the  cells  to  arrange  themselves  in  concentric  groups.  Some  spindle-cell  tissue  is 
shown  in  hands,  and  some  round  cells  without  clearly  denned  cell  bodies  at  the  lower  part  of  the 
field.  The  cells  are  closely  grouped  in  the  denser  portions  of  the  tissue  and  it  seems  almost  im- 
possible to  isolate  individual  elements,  on  this  account  the  faintly  granular  intercellular  substance 
is  not  distinguishable  from  the  cell  bodies  in  these  drawings. 

X  300.     (Reduced  %). 


it]  /    '  r- 
I  !  |p 


a     -5 


£     c 


■s      v      a 


<     -5     .5 


«:  £ 


O        bf; 


zJ?W& 


?§&  lyv.e.  /       Y 


Fig.  42.    Case  601.    Glioma  of  brain,  showing  the  various  shapes  of  the  cells,    x  300.     (Reduced  £.) 


v&&. 


...VK'X  ■■-\'- 


1 H 


JiV-.;:r  (.'^ 


VL V!  .£ 


v  -  ^-  J       x  -\ :      ..  ^  ^  <•     ' 

r....->      ,    -  .  ...*.„....     , 


\A 


a. 


#f     ' 


^V        ,  « 


?^:u::   */*'    W^vr.v 


Fig.  43.    Case  832.    Glioma  of  brain,     x  300.     (Reduced  a.) 


Fig  44.    Case  1053.    Section  of  glioma  of  brain,  showing  the  general  structure,  the  various  shapes 
of  the  cells,  and  a  small  blood  vessel  with  thick  fibrous  walls,     x  300.     (Reduced  a.) 


Fig.  45.  Case  1053.  Section  from  the  looser  portion  of  the  tumor,  showing  the  cells  swollen  and 
rounded  when  uninfluenced  by  pressure;  and  also  a  portion  of  the  wall  of  a  greatly  thickened 
blood  vessel,     x  300.     (Reduced  a.) 


f.yy.B. 


'  T 


Fig.  46.  Case  1053.  Section  of  glioma  of  brain  showing  peculiar  groupingof  the  cells  around 
the  walls  of  a  blood  vessel.  Long  spindle-shaped  cells,  and  astrocytes  send  processes  toward  the 
borders  of  the  perivascular  space,  somewhat  like  the  glia  cells  in  gliosis. 

X  300.    (Reduced1/^). 


£  - 


•a   >g 
£    | 

ad      ^ 


a    £ 


Ji^   . 


^, 


r,,.   ,        ^    ■ , , , 


: 


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<a>J$ 


^mJ? 


i<;K 


ft£ 


|§8t 


fm 


■S        £         4)  -  u 


e-    -    ^ 


® 
^ 


^:^^?^- 


SJ 


;^ 


LS 


~     5 

-1    a 


Fig.  50.  Case  1619.  Small  field  from  glioma,  showing  typical  astrocytes.  In  ordinary  sec- 
tions the  fibres  cannot  be  traced  to  any  great  distance  from  the  cell  bodies.  The  intercellular 
fibrillaeare  probably  mainly  branches  of  cells;  the  nuclei  present  no  visible  protoplasmic  sub 
stance  but  may  also  be  of  glial  origin. 

X  300.     (Reduced  %). 


,'-V 


'> 


Si' 


S  a 


fei&js 


vIcF- 


.*<?(£&% 


Fig.  51.  Case  1610.  Field  from  the  most  vascular  portion  of  the  glioma  of  brain  represented 
in  Figs.  49  and  50.  The  structure  consists  mainly  of  large  blood-channels,  or  dilated  capillaries 
with  a  stroma  of  finely  striated  and  nucleated  connective  tissue.  Some  of  the  nuclei  are  elongat- 
ed and  probably  belong  to  spindle-cells,  but  no  glia  elements  can  be  found  in  these  situations. 

X  300.     (Reduced^). 


jgfc  i  i  ;    . 


i  «*-. 


3 


Fig'  s2-  Case  1619.  Small  field  from  glioma,  showing' the  tissue  bordering  on  a  small  cyst- 
like cavity  filled  with  the  products  of  degeneration,  The  large  round  cells  resemble  those  found 
in  the  vicinity  of  cerebral  softenings,  and  are  probably  altered  neuroglia  elements  from  their  re- 
semblance to  those  seen  at  the  edge  of  the  tumor  tissue  shown  above. 

X  300.     (Reduced  %) . 


RMHHP 

Fig.  53.    Case  820.    Glio-sarcoma  of  brain,     x  300.     (Reduced  f) 


tyv.s. 


Fig.  54.  Case  1237.  Small  round-celled  sarcoma  of  brain.  Numerous  sections  of  blood  vessels 
with  walls  composed  of  a  single  layer  of  endothelium,  or  flattened  sarcomatous  cells,  are  seen 
in  the  field,     x  300.     (Reduced  §.) 


Fig.  55.  Case  1237.  Low-power  view  of  the  advancing  border  of  round-celled  sarcoma,  as  it  en- 
croaches upon  the  white  matter  of  the  hippocampus  major.  The  growth  seems  to  follow  the 
adventitia  of  a  small  artery  which  extends  to  some  distance  into  the  tumor  tissue,     x  50. 


Tig.  56.  Case  1237.  Advancing  border  of  round-celled  sarcoma  of  brain.  Showing  large  band  of 
connective  tissue,  probably  derived  from  the  pia  mater.  Two  concentrically  striated  calcareous 
bodies  are  seen  near  the  edge  of  the  tumor  tissue,     x  300.     (Reduced  £.) 


- 


»",^i-uV    .  v'r/.J  / 


""',    "'   2  fi|  Mi-7*-"" 

Fig.  57.    Section  of  normal  pituitary  body,  to  compare  with  the  adenoma  in  Case  788.     x  300. 

(Reduced  £.) 

>J  "'  '   I      >  ,K  '      v'  '\?\       sac"       ^S:« 

4t 


-far 

Kg.  58.    Section  of  normal  pituitary  body,     x  300.     (Reduced  £.) 


Km 


'■felll  i  :  .  = 


"OB 


msm 


\;i«Mi«sk.     '  -  &  3,;,v^  lip 


&m  \<&  i 


t^ 


ijg  .<*•<£ 


^;^,»;o/l^r  '    ■ 


wmk 


\  Ifif 
.(ill 


> 


Fig.  59.    Section  from  normal  adult  pituitary  body,     x  300.    (Reduced  f.) 


8&4i  «m^%\    '  ■  ^5S,-i?;.,t:V-'.'.:  7  #  • 

'm     h:     -frf 

".".  -:>-■:>,-./.   ■  '/:;■--  ■;■■•-.-.  T-'V: 


Fig.  CO. 


m 

'4,     V 


r^  ■  ■  v'^. .-*,'-  •-(&:  •  ■«?.  .-.$;■■  r*"1  -  .'^i 


&% 


»  ^l§ 


-It. . .     ..    **!' V 


t-;^; 


PS 


§ 


ft  : 


Fig.  62.    Case  788.    Section  from  adenoma  of  pituitary  body,     x  300.     (Reduced  |.) 


Section  from  looser  portion  of  the  pituitary  adenoma,     x  200.     (Reduced}.) 


Fig.  64.    Case  788.    Papillary  growth  in  pituitary  adenoma,     x  300.     (Reduced  K 


*•) 


Fig.  65.    Case  870.    Adenoma  of  the  pituitary  body,     x  300.     (Reduced  |.) 


DESCRIPTION  OF  PLATES. 

Plate  I  {Case  853). — Section  through  the  tumor  near  its  middle,  showing  its  rela- 
tion to  the  calcarine  fissure  and  the  median  surface  of  the  occipital  lobe;  and 
the  encroachment  upon  the  posterior  horn  of  the  ventricle.  The  section  was 
made  after  hardening  the  brain;  the  definition  between  the  brain  tissue  and  that 
of  the  tumor  is  therefore  not  so  distinct  as  in  the  fresh  condition. 

Plate  II  (Case  842). — View  of  the  tumor  of  the  frontal  lobes  seen  from  the  base. 
The  relative  size  and  the  position  are  well  shown. 

Plate  III  (Case  842). — Median  section  of  the  brain  showing  half  the  tumor  in  situ. 
The  displacement  of  the  brain  structures  is  well  shown.  The  small  portion  of 
falx  which  was  adherent  to  the  tumor  is  seen  in  position. 

Plate  IV  (Case  774)- — This  plate  represents  the  median  section  of  the  brain,  and 
shows  the  tumor  in  the  frontal  lobes  and  the  displacement  of  the  brain  struc- 
tures by  it.  A  small  portion  of  the  falx  was  left  in  situ  to  show  its  adhesions  to 
the  tumor.  To  prevent  glistening  of  the  surface  the  photographs  of  fresh  speci- 
mens were  taken  under  water  by  the  use  of  a  mirror.  The  pictures  of  such  are, 
therefore,  marked  "reversed."  It  will  be  observed  that  this  tumor  is  in  the 
same  situation,  and  it  has  almost  the  same  structure,  as  that  shown  in  PI.  III. 
The  situation  seems  to  be  rather  a  common  one  for  tumors  of  this  kind,  but  for 
what  reason  is  not  clear. 

Plate  V  (Case  1146). — Soft  carcinoma  of  the  pyloric  end  of  the  stomach.  The 
pylorus  was  laid  open  by  a  section  running  parallel  with  the  long  axis  of  the 
stomach.  The  darker  portions  of  the  tumor  were  ulcerated  and  hemorrhagic. 
The  picture  shows  portions  of  stomach  and  duodenum;  the  walls  of  the  former 
somewhat  thickened.  A  tumor  of  the  dura  mater  which  coexisted  in  this  case 
was  not  photographed.     See  figs.  12,  13,  and  14. 

Plate  VI  ( Case  1503). — Spindle-celled  endothelial  sarcoma  of  the  dura  mater,  pene- 
trating the  brain  at  the  anterior  portion  of  the  right  frontal  lobe.  A  small 
portion  of  the  dura  is  left  adherent  to  indicate  the  origin  of  the  growth.  The 
third  frontal  convolution  is  seen  to  be  pushed  upward  and  backward. 

Plate  VII  ( Case  1178).— -This  plate  shows  a  section  made  exactly  through  the  center 
of  the  spindle-celled  sarcoma  of  the  dura  mater.  A  section  of  the  skull  was 
also  made  and  placed  in  position  to  be  photographed.  The  elevation  of  the 
inner  surface  of  the  bone  at  the  point  of  origin  of  the  tumor  is  thus  seen  in  situ. 
The  section  shown  includes  the  dura  over  the  convexity  which  was  adherent  to 
the  tumor,  the  falx,  and  tentorium.  The  photograph  shows  the  lines  of  con- 
nective tissue  which  radiate  from  the  place  of  origin  of  the  tumor  and  intersect 
it  in  every  direction.  The  growth  of  the  tumor  from  the  dura,  its  evident 
encroachment  upon  the  brain,  and  the  well-defined  boundaries  of  the  growth 
are  clearly  shown. 

Plate  VIII  (Case  1178). — The  outline  diagram  shows  the  situation  of  the  tumor, 
its  encroachment  on  the  cortical  motor  areas,  and  the  line  of  section  shown  by 
PL  VII. 

Plate  IX  (Case  1130). — Hemorrhagic  spindle-celled  sarcoma  of  cerebellum.  The 
plate  shows  the  inferior  view  of  the  cerebellum  with  the  tumor  in  situ.  The 
relative  size  of  the  growth  the  depression  made  in  the  cerebellum  and  the  dis- 
placement of  the  pons  are  well  shown. 

Plate  X  (Case  1130). — Superior  view  of  cerebellum  and  tumor.  The  photograph 
shows  the  tumor  in  place,  the  increased  bulk  of  the  left  hemisphere  of  the 
cerebellum  from  the  presence  of  the  tumor,  the  fifth  nerve  stretched  over  the 
growth,  and  the  lateral  displacement  of  the  pons. 

Plate  XI  (Case  1130). — The  plate  shows  the  larger  soft  fibromata  of  the  skin, 
though  hundreds  of  minute  nodules  are  invisible  owing  to  the  small  size  of  the 
photograph.  The  tumors  were  especially  numerous  on  the  forehead  and  arms. 
The  coexistence  of  multiple  soft  fibromata  of  the  skin  with  tumor  of  the  cere- 
bellum was  deemed  of  sufficient  interest  to  introduce  this  plate,  though  there 
was  evidently  no  ^etiological  relationship  between  the  growths. 

Plate  XII  ( Case  965). — View  of  the  base  of  the  brain,  showing  the  tumor  in  the  basal 
portion  of  the  temporal  lobe.  The  flat  portion  of  the  tumor,  which  rested  on  the 
tentorium,  is  shown,  and  also  the  displacement  of  the  occipito-temporal  convolu- 
tions, and  the  proximity  of  the  growth  to  the  crus  and  pons.  The  photograph 
is  reversed. 

7 


8  GOVERNMENT    HOSPITAL    FOR    THE    INSANE. 

Plate  XIII  (Case  965). — This  section  of  the  brain  shows  the  depth  to  which  the 
tumor  had  penetrated  and  the  displacement  of  the  convolutions  by  it.  The  sec- 
tion passed  exactly  through  the  middle  of  the  growth. 

Plate  XI V  ( Case  1582). — Spindle-celled  endothelial  sarcoma  of  the  dura  mater 
penetrating  the  lower  portion  of  the  temporal  lobe.  The  growth  is  seen  in  pro- 
file and  therefore  appears  smaller  than  the  actual  size. 

Plate  XV  (Cas(  105S). — Median  section  of  the  brain,  showing  the  glioma  of  the 
corpus  callosum  and  frontal  lobes.  The  degeneration  and  hemorrhage  in  the 
central  portions  of  the  growth  are  clearly  shown,  and  the  swollen  convolutions 
in  the  vicinity  with  the  cerebral  arteries  embedded  in  them. 

Plate  XVI  [Case  I486). — Section  through  the  middle  of  a  glioma  of  the  left  frontal 
lobe.  It  may  be  seen  by  the  dotted  line  which  marks  the  apparent  limits  of  the 
growth,  that  the  tumor  tissue  did  not  reach  the  surface  membranes  and  that  it 
extended  to  the  roof  of  the  lateral  ventricle.  The  small  cystic  cavity  shown  at 
(a)  is  one  of  those  not  uncommon  in  gliomata. 

Plate  XVII  (Case  1619). — Horizontal  section  of  the  brain  showing  a  large  hem- 
orrhagic glioma  occupying  the  left  frontal  lobe.  The  increased  size  of  the  lohe, 
the  encroachment  upon  the  insula,  and  the  pressure  upon  the  basal  ganglia  and  the 
internal  capsule  are  well  shown  in  the  picture.  The  tumor  evidently  originated 
in  the  white  matter,  did  not  extend  to  the  membranes,  and  the  outer  portion  of 
the  cortex  was  unaffected.  Several  small  softened  areas  are  seen  in  the  basal 
ganglia  the  result  of  disease  of  the  cerebral  arteries. 

Plate  XVIII  ( Case  1619). — Upper  half  of  the  brain  showing  the  glioma  in  situ.  The 
increase  in  the  size  of  the  lobe  and  the  pressure  upon  the  central  structures  are 
well  shown  in  this  section.  The  tumor  tissue  with  the  alternating  degenerated 
and  hemorrhagic  areas  presents  a  mottled  appearance  which  clearly  defines  the 
limits  of  the  growth. 

Plate  XIX  ( Case  820). — This  plate  represents  the  external  appearance  of  the  glioma 
of  the  brain  found  in  this  case.  The  color  of  the  affected  region  gave  it  a  dark 
shade  in  the  photograph,  and  the  alteration  of  shape  of  the  affected  temporal 
lobe  is  well  shown.  A  portion  corresponding  to  the  uncinate  gyrus  is  much 
enlarged  and  has  pressed  aside  the  optic  nerves  and  the  crus. 

Plate  XX  (Case  1237). — Round-celled  sarcoma  of  the  brain;  shown  by  section 
through  the  corpus  callosum,  median  line  of  cerebellum,  and  into  the  posterior 
cornua  of  the  lateral  ventricles.  The  fungoid  masses  which  grew  into  the  ven- 
tricles are  well  shown.  To  distinguish  the  tumor  masses  from  the  brain  sub- 
stance fine  stippling  has  been  used. 

Plate  XXI  (Case  1237). — This  plate  shows  a  view  of  the  same  tumor  after  removal 
of  the  superior  portions  of  the  hemispheres  on  a  level  with  the  basal  ganglia. 
The  plate  shows  more  clearly  the  fungoid  tumor  masses,  the  great  enlargement 
of  the  lateral  ventricles  owing  to  obstruction  of  the  aqueduct  of  Sylvius  by  the 
growth  of  the  tumor,  and  the  extensive  invasion  of  the  cerebellum.  The  appar- 
ent asymmetry  of  the  two  hemispheres  is  due  to  distortion  during  hardening 
after  sections  had  been  made. 

Plate  XXII  (Case  788).— In  this  plate  the  adenoma  of  the  pituitary  body  is  shown 
in  situ.  The  displaced  nerves  and  arteries  are  seen  around  the  tumor.  The 
rough  surface  is  the  portion  which  was  removed  from  the  pituitary  fossa. 

Plate  XXIII  (Case  788). — This  plate  shows  the  depression  made  by  the  pituitary 
tumor  in  the  base  of  the  brain.  The  structures  which  were  displaced  and  pressed 
upon  may  all  be  seen. 

Plate  XXIV  ( Case  870). — This  plate  shows  the  base  of  the  brain  with  the  pituitary 
tumor  in  situ.  The  relative  size  of  the  growth  is  well  shown,  and  the  extreme 
separation  of  the  arteries  of  the  circle  of  Willis,  the  olfactory  nerves,  optic  nerves, 
and  the  basal  portions  of  the  temporal  lobes.  The  optic  nerves  lie  apparently 
turned  backward  over  the  tumor,  and  the  chiasma  may  be  seen  stretched 
between  them.  The  third  nerves  may  be  seen  between  the  pons  and  the  tumor. 
The  darker  portion  of  the  tumor  is  that  which  was  dissected  from  the  pituitary 
fossa. 

Plate  XXV  (Case  870). — This  plate  represents  the  median  surface  of  the  brain  and 
the  pituitary  tumor,  photographed  after  hardening.  The  specimen  was  somewhat 
flattened  by  lying  on  the  convexity  and  the  pia  mater  was  wrinkled  by  shrinkage 
of  the  brain  tissue.  The  size  of  the  growth  and  its  encroachment  upon  the  ven- 
tricular cavity  are  well  shown.  The  cut  surface  of  the  tumor  presents  a  more 
granular  appearance  than  in  the  fresh  condition.  A  slight  constriction  marks  off 
the  portion  which  lay  in  the  enlarged  pituitary  fossa.  The  parts  within  the 
ventricular  cavity  immediately  adjoining  the  tumor  being  extremely  soft  at  the 
time  of  the  autopsy  did  not  harden  well  and  are  therefore  not  well  defined  in 
the  picture. 


GOVERNMENT    HOSPITAL    FOR   THE    INSANE.  9 

Plate  XXVI  (Case  991). — Section  of  cerebellum,  showing  tubercular  tumor. 
Plate  XXVII  (  Case  805). — Aneurism  of  the  right  middle  cerebral  artery.     The  dis- 
placement of  the  middle  cerebral  artery,  the;  optic  nerves,  the  third  nerve,  and 
the  adjoining  portion  of  the  temporal  lobe  is  well  shown.     The  adherent  ten- 
torium and  a  small  calcareous  nodule  are  seen  on  the  surface  of  the  tumor. 
Plate  XXVIII  (Case  805). — View  of  a  dissection  showing  a  quarter  section  of  the 
aneurismal  sac  left  in  situ.     The  opening  which  existed  in  the  artery  still  com- 
municated with  the  aneurismal  sac,  though  the  cavity  was  about  filled  up  with 
a  dry,  friable  mass  of  altered  blood  clot.     The  opening  is  easily  seen  and  the 
posterior  communicating  artery  is  distinguished  by  a  bristle  passed  through  it. 
Plate  XXIX  (Case  1246). — Photograph  of  the  interior  of  a  scaphoid  calvaria,  show- 
ing hyperostoses  of  the  inner  table  of  the  frontal    bone  and   small  nodular 
exostoses  along  the  line  of  the  obliterated  sagittal  suture. 
Plate  XXX. — Group  of  several  small  irregularly-shaped  osteomata  such  as  are  fre- 
quently found  in  the  falx  cerebri.     The  specimens  are  from  several  cases.    They 
are  photographed  natural  size. 
Note. — The  plates,  drawings,  and  cases  are  arranged  without  reference  to  numeri- 
cal order,  the  object  being  to  show  the  progressive  development  of  the  tumor  tissue 
from  the  simpler  to  the  more  complex  forms.     This  seemed  to  be  especially  impor- 
tant in  case  of  the  spindle-celled  endothelial  sarcomata,  illustrated  by  31  microscop- 
ical drawings,  showing  the  development  of  this  tumor  tissue  and  the  degenerative 
modifications  to  which  it  owes  its  complexity. 

DESCRIPTION  OF  DRAWINGS. 

SPINDLE-CELLED  endothelial  sarcomata. 

Fig.  1  (Cose  853). — This  drawing  represents  the  denser  portion  of  the  growth. 
Several  cell  whorls  are  represented,  some  with  commencing  hyaline  degenera- 
tion in  the  central  portions.  Longitudinal  and  transverse  sections  of  spindle- 
cell  groups  are  seen  running  between  the  closely  packed  cell  nests.  Near  the 
center  of  the  drawing  is  a  blood  vessel  with  thickened  hyaline  wall,  surrounded 
by  circularly  arranged  spindle  cells.  The  bodies  of  the  cells,  being  faintly 
stained  and  closely  applied  to  each  other,  are  scarcely  distinguishable  in  sections. 

Fig.  2  (Case  853). — Section  from  the  looser  portion  of  the  tumor,  where  the  spindle 
cells  are  more  curled  and  are  more  irregular  in  arrangement.  Several  cell  whorls 
are  represented,  some  showing  a  tendency  to  hyaline  change  in  their  centers. 
Two  small  hyaline  spherules  are  seen  at  the  left  of  the  drawing,  and  capillary 
blood  vessels  in  transverse  and  longitudinal  section. 

Fig.  3  (Case  84%) ■ — This  section  shows  some  spindle-cell  bands  running  longitudi- 
nally, and  transverse  sections  of  three  others.  This  tumor  is  almost  identical 
with  the  one  represented  in  fig.  4,  Case  774. 

Fig.  4  ( Case  774)- — In  this  drawing  are  represented  parts  of  four  lobules  or  groups  of 
cells  with  delicate  connective  tissue-carrying  blood  vessels,  running  between 
them.  The  cell  groups  consist  of  cell  nests  and  bands  of  spindle  cells  running  in 
every  direction.  Some  transverse  sections  of  spindle  cells  may  be  recognized 
by  the  round  sections  of  their  nuclei.  The  intercellular  substance  is  scanty  and 
the  cell  bodies  are  hard  to  distinguish  in  the  sections. 

Fig.  5  (Case  1436). — This  drawing  shows  the  general  structure  of  the  tumor.  It  is 
seen  to  be  composed  mainly  of  spindle-cell  elements  arranged  in  bands  and 
whorls.  Several  of  the  latter  are  shown  with  a  few  round,  clear  cells  in  their 
centers,  visible  by  careful  focusing.  Occasionally  groups  of  spindle  cells  are  cut 
transversely,  when  the  nuclei  appear  round.  Two  blood  vessels  with  fibrous 
walls  containing  slender  elongated  nuclei  are  shown  in  the  field.  The  stippling 
used  for  shading  gives  a  granular  appearance  which  is  not  present  with  low 
amplification. 

Fig.  6  (Case  1436). — This  drawing  was  taken  from  the  line  of  junction  between  the 
dura  and  the  tumor  to  show  the  gradual  transition  from  membrane  to  tumor 
tissue.  Usually  the  tumor  structure  contained  many  large  blood  vessels  at  the 
junction  with  the  dura,  and  the  adjoining  dural  vessels  were  engorged.  The  sec- 
tion shows  two  small  concentrically  arranged  cell  groups. 

Fig.  7  (Case  76). — Section  of  tumor  of  brain,  showing  one  very  large  and  three 
small  hyaline  globes,  and  a  cell  nest  composed  of  closely  packed  spindle  cells. 
In  the  center  of  the  large  hyaline  body  are  several  nuclei  and  a  little  granular 
matter,  and  a  few  flattened,  rod-shaped  nuclei  are  seen  between  the  lamina?. 

Fig.  8  (Case  76). — Section  from  the  same  tumor,  showing  two  cell-nests  and  two 
very  dense  hyaline  bodies. 


10  GOVERNMENT    HOSPITAL    FOR    THE    INSANE. 

Fig.  9  (Case  715). — In  this  drawing  are  seen  several  small  hyaline  globules  lying  in 
the  centers  of  cell-nests;  a  few  small  cell-nests  which  show  no  hyaline  change; 
a  longitudinal  view  of  a  cylinder  of  hyaline  material  in  the  center  of  a  hand  of 
spindles,  and  several  blood  vessels  surrounded  by  spindle  cells.  It  is  impossible 
to  represent  the  hyaline  material  perfectly  with  pen  and  ink. 

Fig.  10  (Case715). — This  drawing  represents  a  very  large  hyaline  globe  from  the 
same  tinnor,  with  its  investing  layers  of  closely  applied  spindle  cells.  Such 
bodies  are  distinctly  visible  to  the  naked  eye. 

Fig.  11  (Case  715). — Section  of  the  tumor  of  the  falx  enlarged  one-third,  showing  the 
shape  of  the  tumor  and  its  relation  to  the  falx  and  dura. 

Fm.  12  (Case  1146). — This  section  represents  a  spindle-celled  endothelial  sarcoma, 
which  has  become  fibrous  and  has  undergone  hyaline  degeneration,  which  ren- 
ders the  nuclei  indistinct  and  the  cells  nearly  indistinguishable  as  such.  In  the 
lower  middle  portion  is  a  concentrically  striated,  fibrous,  and  hyaline  body,  which 
represents  a  small  concentrically  arranged,  spherical  cell  mass  which  has  become 
so  degenerated.  A  number  of  these  spherules  of  fibrous  appearance,  with  scarcely 
visible  nuclei,  are  seen  in  the  middle  diagonal  line  of  the  picture.  These  masses 
show  all  stages  of  degenerative  change,  from  the  spherical  cell  mass  to  the  hya- 
line and  calcified  globular  masses  such  as  are  represented  in  the  drawing.  The 
almost  homogeneous  appearance  of  the  degenerated  tumor  tissue  is  represented 
by  tine  stippling,  though  the  tissue  was  not  granular  under  the  microscope.  The 
fibrous  change  in  the  cellular  tissue  and  the  hyaline  degeneration  gave  the  growth 
a  close  resemblance  to  hard  fibroma,  and  in  fact  a  considerable  amount  of  real 
fibrous  tissue  was  found  present.  Vessels  were  not  numerous,  and  those  found 
were  imperfectly  developed  and  hyaline.  The  growth  was  unquestionably  of 
dural  origin,  though  its  exact  histogenesis  was  impossible  to  determine. 

Fig.  13  (Case  1146). — This  drawing  represents  a  soft  carcinoma  of  the  pyloric  region 
of  the  stomach.  The  cells,  when  not  influenced  by  pressure,  are  round,  with 
prominent  nuclei ;  when  closely  packed  they  are,  of  course,  polymorphic.  In  some 
of  the  alveoli  the  peripheral  cells  show  a  tendency  to  arrange  themselves  in  a 
single  layer  and  to  assume  a  columnar  shape  from  mutual  pressure.  This  is  about 
the  only  trace  of  gland-like  structure,  except  that  the  size  and  character  of  the 
cells  suggest  the  fundus  cells  of  the  pyloric  glands,  from  which  they  probably 
originated.  The  stroma  is  scanty,  it  forms  very  small  alveoli,  and  it  is  less 
nucleated  than  usual  in  such  tumors. 

Fig.  14  (Case  1146). — This  section  was  drawn  to  show  the  penetration  of  the  cancer 
cells  into  the  connective  tissue  trabecule,  between  the  muscular  bundles  of  the 
circular  layer  of  the  muscular  coat  of  the  stomach.  Two  cancer  cell-nests  are 
shown  lying  in  the  midst  of  the  dense  cellular  infiltration  of  the  connective  tissue. 
The  muscular  bundles  are  cut  transversely,  as  the  section  was  made  parallel  to 
the  long  axis  of  the  stomach. 

These  two  drawings  were  here  introduced  on  account  of  the  interest  attached 
to  the  presence  of  two  tumors  of  different  character  in  the  same  subject. 

Fig.  15  (Case  1516). — In  this  drawing  are  shown  a  number  of  hyaline  spherules 
and  three  longitudinal  sections  of  hyaline  bands  or  rods  such  as  were  found  in 
some  parts  of  this  growth.  These  rods  of  hyaline  material  are  evidently  of  cell 
origin,  as  they  sometimes  show  remains  of  elongated  nuclei  and  are  commonly 
found  in  the  midst  of  bands  of  spindle  cells.  In  some  tumors  of  this  class  hya- 
line degeneration  may  affect  any  of  the  constituents  of  the  tumor,  and  hyaline 
material  may  even  be  found  in  minute  spherules  and  droplets  apparently  not  of 
cell  origin. 

Figs.  16-20  (Case  1516). — These  drawings  show  the  various  stages  of  hyaline  trans- 
formation of  the  cell  spherules  from  the  concentrically  arranged  cell  groups  to 
the  hyaline  spherules,  which  could  hardly  be  distinguished  as  of  cellular  origin. 

Fig.  21  (Case  1516). — This  drawing  shows  a  field  from  the  same  tumor  composed 
of  closely  set  cell  spherules  of  small  size,  partly  transformed  into  hyaline  globes. 
The  small  spherules  are  separated  by  a  little  spindle-celled  tissue  cut  in  every 
direction.  The  partly  hyaline  spherules  still  show  the  nudei  of  the  cells 
arranged  concentrically  as  in  fig.  20. 

Fig.  22  (Case  965). — This  drawing  shows  the  structure  of  this  curious  growth  under 
a  moderately  high  power.  The  characteristic  feature  of  the  structure  is  the 
presence  of  great  numbers  of  round  and  oval  hyaline  bodies,  which  are  believed 
to  be  the  products  of  some  form  of  degeneration  of  the  closely  packed  cell 
whorls,  one  of  which  remains  unchanged  in  the  field  represented.  The  drawing 
shows  a  number  of  these  bodies  of  various  sizes,  some  of  which  show  calcifica- 
tion of  their  central  portions.  They  nearly  all  show  flattened,  elongated  nuclei 
between  some  of  the  lamina?,  which  are  supposed  to  be  remnants  of  the  cells  of 


GOVERNMENT    HOSPITAL    FOR    THE    INSANE.  11 

the  original  cell-nests  or  whorls.  The  large  body  in  the  center  of  the  drawing 
is  composed  of  three  globular  bodies  which  have  coalesced  and  are  surrounded 
by  a  common  capsule.  Similar  cell  arrangements  are  seen  in  some  tumors  of 
this  class,  as  shown  in  rig,  4,  Case  774. 

The  cells  remaining  between  the  hyaline  globes  are  mainly  spindle-shaped,  and 
run  in  bands  in  every  direction.  Sometime  several  layers  of  cells  are  arranged 
circularly  around  some  of  the  hyaline  spherules.  In  some  small  areas  the  cells 
seem  to  be  nearly  all  round,  but  as  the  spindle  cells  predominate  the  tumor  may 
be  regarded  as  a  spindle-celled  sarcoma,  or  psammo-sarcoma. 

Fig.  23  {Case  965).—  Low-power  drawing  of  the  same  tumor,  showing  the  great 
number  of  hyaline  spherules  found  throughout  the  growth,  and  the  small  pro- 
portion of  cell  structure  which  remains  between  them.  Near  the  center  of  the 
drawing  two  of  the  bodies  have  been  displaced  and  one  is  partly  turned  over,  so 
that  the  cut  edge  is  shown.  Several  empty  spaces  are  seen  in  the  drawing,  the 
spherules  having  been  displaced  by  the  section  knife.  At  the  upper  border  of 
the  drawing  two  spherules  have  coalesced;  several  show  calcined  centers,  and 
nearly  all  have  flattened  nuclei  between  some  of  the  laminae. 

Fig.  24  {Case  1503).—  Section  showing  the  general  structure  of  endothelial  sarcoma 
of  the  dura  mater.  The  drawing  shows  numerous  cell-groups  consisting  of 
round  and  polygonal  cells  in  the  centers,  spindle-shaped  elements  at  the  periph- 
ery, and  delicate  spindle-celled  tissue  separating  them.  A  number  of  blood 
vessels  with  thick  hyaline  walls  and  scarcely  distinguishable  lumen  are  shown 
cut  in  various  directions.  At  the  lower  part  of  the  drawing  a  portion  of  one  of 
the  very  large  hyaline  cell  masses  is  shown.  These  bodies  show  concentric  stri- 
ation,  the  nuclei  of  degenerated  cells,  and  sometimes  calcification.  To  ordinary 
magnification  the  hyaline  material  is  homogeneous;  the  stippling  is  used  for 
shading. 

Fig.  25  {Case  1503). — Higher-power  view  of  the  same  tumor  showing  details  of 
structure.  Portions  of  several  cell-groups  are  shown  with  the  delicate  strands  of 
spindle-cell  tissue  between  them.  An  attempt  has  been  made  to  get  the  effect 
of  the  nearly  clear  cell  protoplasm  by  fine  stippling,  and  the  difficulty  of  distin- 
guishing the  outlines  of  the  round  central  cells  is  shown  by  faint  outlines  of  some 
of  the  cell  bodies.  Four  hyaline  spherules  of  small  size  are  shown,  and  two 
blood  vessels  with  thickened  walls  lying  in  a  small  quantity  of  fibrous  tissue. 

Fig.  26  {Case  1582). — Spindle-celled  endothelial  sarcoma  of  dura  mater.  The  sec- 
tion shows  the  general  structure  of  the  growth.  Cell  groups  run  in  every  direc- 
tion, some  closely  applied  to  each  other  and  some  separated  by  what  appears  to 
be  hyaline  fibrous  tissue.  Several  hyaline  spherules  in  various  stages  of  degen- 
eration, are  seen  in  the  field  and  a  small  blood  vessel  with  thick  fibrous  walls  is 
shown  in  the  middle  of  the  drawing. 

Fig.  27  {Case  1582). — Section  from  the  same  tumor  showing  a  large  curved  blood 
vessel  cut  longitudinally,  exposing  the  lumen,  and  several  small  vessels  with  thick 
fibrous,  partly  hyaline  walls,  cut  transversely.  The  wall  of  the  large  vessel  is 
seen  to  be  composed  mainly  of  spindle  cells  arranged  circularly  and  in  many 
layers.  The  curved  portions  of  the  vessel  not  in  the  line  of  section  show  clearly 
the  circularly  grouped  cells  with  elongated  oval  nuclei,  the  cut  portions  of  the 
wall  show  transverse  sections  of  the  same,  and,  by  section  of  the  lumen,  expose 
the  large  oval  nuclei  of  the  endothelium  which  lie  parallel  with  the  length  of 
the  vessel.  The  oval  nuclei  in  the  lumen  which  lie  transverse  to  the  vessel  are 
optical  sections  of  the  spindle-cell  nuclei  seen  through  the  intima.  I  have  not 
been  able  to  decide  as  to  the  nature  of  these  spindle  cells  surrounding  the  vessels, 
but  I  believe  them  to  be  the  same  as  those  composing  the  main  mass  of  the 
tumor,  and  that  they  undergo  hyaline  change  and  form  the  thick-walled  hyaline 
vessels  such  as  shown  in  the  next  drawing.  In  the  upper  left  corner  is  a  small 
hyaline  spherule,  and  in  the  curve  of  the  vessel  a  small  concentrically  arranged 
cell  group  is  seen. 

Fig.  28  ( Case  1582). — This  field  shows  a  group  of  blood  vessels  with  greatly  thickened 
and  hyaline  walls.  In  some  parts  of  this  tumor  blood  vessels  were  very  numerous 
and  were  usually  more  or  less  thickened  and  hyaline,  though  some  still  showed 
the  fibrous  tissue  or  the  spindle  cells  of  which  the  walls  were  made  up.  The 
lumen  was  usually  preserved  and  filled  with  blood,  though  obliteration  of  the 
vessels  was  only  a  matter  of  degree.  The  endothelium  and  intima  were  usually 
quite  distinct  and  stained  well,  the  hyaline  walls  stained  a  pale  pink  in  hema- 
toxylin and  eosin.  In  the  drawing  fine  stippling  was  used  to  represent  the 
homogeneous  hyaline  degeneration  and  faint  concentric  striations  to  show7  the 
traces  of  the  original  constituents  of  the  vessel  walls. 


12  GOVERNMENT    HOSPITAL    FOR    THE    INSANE. 

Fig.  29  (Case  117S). — Section  from  spindle^celled  endothelial  sarcoma  of  the  dura 
mater.  The  drawing  shows  the  general  structure  of  the  tumor,  which  is  coui- 
posed  of  delicate  spindle  cells  closely  applied  to  each  other  so  that  the  contour  of 
the  cells  is  scarcely  distinguishable,  and  the  tissue  is* mainly  recognized  by  the  cell 
nuclei.  The  tendency  of  the  cells  to  arrange  themselves  in  globular  or  oval  whorls, 
whicb  was  not,  however,  a  marked  feature  in  this  tumor,  is  seen  in  the  center  of 
the  drawing,  while  broad  curved  bands  of  cells  are  shown  in  the  general  cell  mass. 
At  the  lower  part  of  the  picture  is  represented  one  of  the  broad  bands  of  connect- 
ive tissue  which  intersect  the  tumor  in  every  direction  and  separate  the  cell  tissue 
into  lobules.  The  connective  tissue  bands  seem  to  radiate  from  the  dura  at  the 
origin  of  the  tumor;  they  are  certainly  of  new  growth,  and  they  seem  to  form  an 
essential  part  of  the  structure.  In  some  tumors  of  this  class  the  connective  tissue 
is  scanty;  it  is  composed  mainly  of  spindle  cells  and  new  fibers,  but  in  this  the  tis- 
sue was  dense  and  fibrous.  The  larger  blood  vessels  were  mainly  found  in  the 
bands  of  connective  tissue,  but  the  cellular  portion  also  contained  a  few  vessels 
showing  the  usual  imperfect  walls  of  sarcomatous  Mood  channels.  Some  round 
cells  are  found  in  looser  portions  of  the  sarcomatous  tissue,  but  perhaps  the  most 
of  the  round  nuclei  lie  in  transverse  sections  of  the  spindle  cells. 

Fig.  30  ('Case  1178). — This  section,  from  the  same  tumor,  shows  a  field  containing  a 
large  blood  vessel  with  enormously  thickened  hyaline  wall,  and  two  smaller 
vessels  nearly  obliterated  by  the  same  process.  -  Some  of  the  cellular  tissue  is 
shown,  part  of  a  sarcomatous  blood  channel,  and  some  patches  of  dense  connect- 
ive tissue.  In  the  vicinity  of  these  large  blood  vessels  the  intercellular  substance 
is  abundant  and  distinctly  fibrillated. 

Fig.  31  (Case  789). — This  drawing  represents  bands  of  spindle  cells  running  between 
and  partly  encircling  two  large  thick-walled  vessels.  The  presence  of  great  num- 
bers of  large  and  small  vessels  is  a  conspicuous  feature  in  this  tumor.  Hyaline 
change  is  seen  in  both  vessel  walls;  inithe  one  it  is  almost  complete,  in  the  other 
it  extends  only  part  way  around.  In  the  right-hand  vessel  the  endothelial  lining 
seems  to  have  become  separated  from  the  vessel  wall  and  blood  has  escaped 
between  them.  In  both  of  the  vessels  the  inner  portion  of  the  wall  shows  pro- 
liferation of  its  cells  and  increase  of  connective  tissue.  A  large  number  of  small 
hyaline  globules,  sometimes  faintly  concentrically  striated,  sometimes  homoge- 
neous, are  found  in  all  parts  of  the  sections.  They  seem  to  beof  the  same  nature 
as  the  hyaline  material  in  the  vessel  walls  and  they  seem  to  be  especially  numer- 
ous in  the  vicinity  of  the  vessels.  I  have  attempted  to  represent  the  hyaline 
material  by  tine  stippling,  but  in  the  sections  it  appears  homogeneous. 

Fig.  32  (  Case  1180).  — Hemorrhagic  spindle-celled  sarcoma  of  cerebellum.  The  sec- 
tion represented  was  taken  from  the  tumor  near  the  seat  of  hemorrhage,  and  the 
hemorrhagic  infiltration  of  the  tumor  tissue  is  seen  at  the  lower  part  of  the  draw- 
ing. An  artery,  with  thick  hyaline  wall,  is  seen  at  the  left,  and  the  remains  of 
another,  which  is  totally  obliterated,  are  seen  at  the  upper  right  corner  of  the 
picture.  The  resemblance  of  transverse  sections  of  hyaline  vessels  to  the  spheri- 
cal hyaline  bodies  of  similar  growths  is  very  striking,  but  in  this  tumor  hyaline 
spherules  were  not  found.  Wavy  bands  of  spindle  cells,  closely  applied  to  each 
other,  are  seen  in  the  field,  and  also  areas  of  considerable  size  where  the  inter- 
cellular substance  is  abundant  and  distinctly  fibrillated.  Some  of  the  round 
nuclei  seen  in  these  areas  are  probably  transverse  sections  of  the  nuclei  of 
spindle  cells. 

Figs.  33  and  34  are  introduced  to  show  the  structure  of  the  soft  fibromata  of 
the  skin  which  coexisted  in  this  case.  They  show  some  slight  resemblance 
to  the  intracranial  tumor,  but  could  have  had  no  histogenetic  relation  to  it. 

Fig.  33  (Case  1130). — The  section  represented  was  taken  from  the  more  cellular  por- 
tion of  one  of  the  soft  fibromata  of  the  skin.  At  first  sight  the  tissue  bears  con- 
siderable resemblance  to  spindle-celled  sarcoma,  to  which  it  is  indeed  closely  allied 
histogenetically  and  structurally.  A  close  study  of  the  growth  shows  that  the 
nuclei  are  irregular  in  size,  elongated,  and  many  are  curved;  they  lie  among  the 
fibers,  and  not  within  spindle  cells,  and  the  internuclear  spaces  are  filled  with 
delicately  fibrillated  connective  tissue,  which  is  relatively  more  abundant  than 
in  sarcoma.  A  small  vein  is  seen  in  longitudinal  optical  section,  and  at  the 
lower  part  a  thick-walled  arteriole  is  cut  transversely.  The  large  endothelial 
nuclei  in  the  wall  of  the  vein  present  a  marked  contrast  with  the  nuclei  of  the 
fibrous  tissue. 

Fig.  34  (  Case  1180). — This  section  shows  the  denser  and  more  fibrous  portion  of  one 
of  the  soft  fibromata  of  the  skin.  It  presents  the  more  typical  appearance  of 
such  growths.  The  nuclei  are  less  numerous,  more  rod-like,  and  more  curved 
than  those  shown  in  fig.  2.     A  small  vessel,  filled  with  blood,  is  cut  transversely 


GOVERNMENT    HOSPITAL    FOR    THE    INSANE.  13 

in  the  lower  part,  and  in  the  upper  left  corner  a  small  collection  of  round  nuclei 
represents  a  center  of  growth.  Coil  glands,  deeper  parts  of  sebaceous  glands, 
deep  hair  follicles,  etc.,  were  found  in  the  outer  portions  of  the  growths  next  to 
the  true  skin,  and  a  few  nerve  fibers  were  occasionally  found  in  the  deeper  parts 
of  the  tumors,  but  as  these  structures  were  only  incidentally  present  they  were 
not  represented. 

Fig.  35  {Case  833).— In  this  drawing  are  seen  one  large  and  several  small  groups  of 
endothelial  cells  surrounded  by  spindle  cells.  Loose  bands  of  spindle  cells  run 
through  the  growth  in  every  direction. 

Figs.  36  and  37  are  given  here  to  show  the  structure   of  the  two  other 
primary  growths  found  in  this  case. 

Fig.  36  (Case  833). — This  drawing  represents  the  common  appearances  of  adenoid 
cancer  of  the  stomach. 

Fig.  37  (Case  833). — This  section  shows  the  small  round-celled  sarcoma  of  the  tes- 
ticle. In  the  center  are  the  remains  of  a  seminiferous  tubule,  and  traces  of  its 
infiltrated  wall  may  be  distinguished  around  it. 

Fig.  38  (Case  539). — This  drawing  shows  some  spindle-cell  bands;  portions  of  fields 
of  large,  round,  and  variously  shaped  endothelial  cells,  which  were  found 
throughout  the  tumor,  and  several  large  blood  vessels  lying  in  loose  connective 
tissue.  In  this  case  the  spindle  cells  were  not  a  predominant  feature;  therefore 
I  have  called  this  growth  an  endothelial  sarcoma,  or  endothelioma. 

Fig.  39  (Case  278). — This  section  shows  the  general  structure  of  the  growth  in  the 
most  cellular  portions.  Spindle-cell  bands  shown  by  the  oval  nuclei  are  repre- 
sented, and  groups  of  round  nuclei  with  granular  internuclear  substance  repre- 
sent transverse  sections  of  spindle-cell  tissue.  In  longitudinal  sections  the 
stroma  is  faintly  striated,  representing  the  outlines  of  the  attenuated  spindle-cell 
bodies;  in  transverse  section  the  internuclear  substance  seems  faintly  granular, 
and  definite  cell  bodies  can  not  be  made  out.  In  some  places  groups  of  round 
cells  may  be  found,  though  these  are  of  course  hard  to  distinguish  from  transverse 
sections"  of  the  spindle-shaped  elements.  In  the  center  of  the  drawing  a  small 
concentrically  arranged  cell  group  is  seen,  and  at  the  upper  part  a  blood  vessel 
with  thin  walls  filled  with  blood. 

Fig.  40  (Case  21 8). — This  field,  from  the  same  tumor,  shows  several  concentric  cell 
groups  with  prominent  nuclei  and  some  spindle-cell  tissue.  At  the  lower  part  of 
the  drawing  are  groups  of  round  cells  which  show  no  visible  protoplasm.  These 
are  found  in  all  parts  of  the  tissue  and  probably  represent  a  younger  stage  of  the 
spindle  cells. 

Fig.  41  (Case  278).—  Section  from  the  same  tumor  represented  in  figs.  39  and  40. 
The  drawing  shows  the  junction  of  the  growth  with  the  dura  mater  from  which 
it  originated.  The  attachments  are  seen  to  be  slight  and  mainly  cellular,  and 
at  the  left  the  two  are  mechanically  separated.  A  lymph  space  filled  with  cells, 
probably  of  endothelial  origin,  is  shown,  the  cells  beginning  to  assume  spindle 
shape  and  to  form  concentrically  arranged  groups  at  the  left.  In  the  central 
portion  a  small  hyaline  spherule  is  seen,  surrounded  by  a  few  spindle  cells. 
Hyaline  globes  were  not  very  common  in  this  growth,  but  in  some  places  the 
vessel  walls  and  bands  of  connective  tissue  showed  the  change  in  its  early  stages. 

GLIOMATA. 

Fig.  42  ( Case  601). — Section  of  glioma  of  the  brain,  showing  the  various  shapes  of  the 
cells,  the  blood  vessels,  and  the  granular  and  indistinctly  fibrillated  intercellular 
substance. 

Fig.  43  ( Case  832) . — This  drawing  shows  two  fields  drawn  from  different  portions  of 
the  tumor.  The  extreme  variation  in  the  size  and  shape  of  the  cells  is  shown. 
The  tumor  differs  widely  in  structure  in  various  regions  of  the  growth,  but  the 
fields  drawn  seem  most  characteristic.  The  diagnosis  was  difficult  on  account 
of  the  degeneration  and  hemorrhage  in  the  growth,  but  it  was  named  glioma. 

Fig.  44  (Case  1053). — Section  of  glioma  of  brain  showing  the  general  structure  of  the 
growth,  the  various  shapes  and  sizes  of  the  cells,  and  a  small  blood  vessel  with 
thick,  fibrous  walls.  Some  of  the  cells  seem  to  be  without  nuclei,  some  are  dis- 
tinctly nucleated;  the  majority  are  more  or  less  branched. 

Fig.  45  (Case  1053). — Section  from  the  looser,  more  degenerated  portion  of  the  same 
tumor.  The  cells,  being  uninfluenced  by  pressure,  are  swollen  and  rounded, 
and  many  are  granular.  The  intercellular  fibrous  tissue  is  scanty.  On  the  right 
is  shown  the  half  of  a  transverse  section  of  a  blood  vessel  wdth  enormously  thick- 
ened wall. 


14  GOVERNMENT    HOSPITAL    FOR    THE    INSANE. 

Fig.  46  [Case  1053). — Section  from  the  same  tumor  showing  a  large  blood  vessel  with 
peculiar  grouping  of  the  glia  cells  around  it.  These  cells  often  show  a  particu- 
larly elongated  branch  which  is  directed  to  the  vessel  wall,  suggesting  the  podas- 
teroid  glia  cells  in  some  forms  of  gliosis.  Whatever  may  be  the  significance  of 
this  disposition  of  the  cells,  they  evidently  have  some  relation  to  the  vessel  walls. 

Fig.  47  {Case  1426). — This  drawing  shows  a  field  from  the  ordinary  structure  of  the 
tumor,  stained  in  hematoxylin.  The  shapes  of  the  cells  were  outlined  carefully 
with  tbe  aid  of  the  camera  lucida;  the  round  cells  or  nuclei  were  outlined  in  the 
same  way  and  subsequently  finished  with  pen  shading.  The  pen  stippling  is  used 
in  these  drawings  merely  as  a  method  of  shading;  under  moderate  amplification 
the  large  branched  and  polymorphous  glia  cells  have  almost  homogeneous  clear 
cell  bodies.  Two  large  blood  vessels  with  their  contents  are  shown  at  the  upper 
part  of  the  drawing.  The  vessels  have  thick  fibrous  walls  and  frequently  show 
accumulations  of  round  cells  in  their  vicinity. 

Fig.  48  (  Case  1426). — This  section  shows  a  portion  of  the  same  tumor  containing  a 
small  area  of  cancer-like  alveoli  containing  cells  epithelial  in  character  arranged 
in  characteristic  groups.  These  cells  stain  deeper  than  the  gliomatous  cells  and 
are  more  granular.  On  the  left  is  shown  the  true  gliomatous  tissue  separated 
from  the  alveoli  by  a  band  of  condensed  and  fibrous  tissue,  but  evidently  of  the 
same  character  as  the  tumor. 

Fi<;.  4H  (  Case  1619). — Glioma  of  brain.  Field  showing  the  general  structure  of  the 
tumor  in  the  most  characteristic  situations.  The  tissue  consists  of  large  glia  cells 
of  almost  every  shape,  lying  in  a  stroma  made  up  of  delicate  fibrillse  richly  nucle- 
ated. The  large,  nearly  homogeneous  bodies  of  the  glia  cells  stain  faintly  in 
the  usual  nuclear  dyes,  and  the  nuclei  stain  more  distinctly  but  are  not  always 
visible;  the  apparently  free  nuclei  stain  deeply  and  are  quite  granular.  The 
large  elements  are  unquestionably  glia  cells;  the  nuclei  may  also  belong  to  the 
glia  tissue,  but  I  see  no  reason  why  they  may  not  be  mesoblastic  in  origin  as  are 
the  blood  vessels  and  the  fibrous  tissue  sometimes  found  in  considerable  quan- 
tity in  these  tumors.  The  intercellular  fibrillar  are  probably,  to  a  great  extent, 
processes  of  the  gliacytes. 

Fig.  50  (Case  1619). — Small  field  from  the  same  glioma,  showing  better  the  shapes  of 
the  astrocytes  and  the  intercellular  fibrilke.  A  few  free  nuclei  are  seen,  appar- 
ently unconnected  with  the  fibers. 

Fig  51  (Case  1619). — Field  from  the  most  vascular  portion  of  the  same  tumor,  show- 
ing a  structure  composed  of  large  blood  channels,  with  a  stroma  made  up  of 
delicately-striated  fibrous  tissue  with  round  and  oval  nuclei.  The  elongated 
nuclei  probably  belong  to  spindle-shaped  cells,  though  no  typical  glia  cells  could 
be  found  in  these  situations.  The  walls  of  the  blood  channels  apparently  consist 
only  of  endothelium. 

Fig.  52  (Case  1619). — Small  field  from  the  same  tumor,  showing  the  tissue  bordering 
on  a  cyst-like  space,  filled  with  homogenous  product  of  degeneration.  Large 
groups  of  round  nucleated  cells  of  various  sizes  are  found  along  the  edges  of  these 
cysts  of  softening.  They  resemble  the  large  cells  found  in  the  vicinity  of  cere- 
bral softenings,  and  are  probably  altered  glia  cells,  as  shown  by  their  resemblance 
to  the  fixed  gliacytes  in  the  unsoftened  tissue  adjoining.  In  addition  to  these 
round  cells,  large  fields  were  made  up  of  small  round  elements,  with  distinct 
nuclei  lying  in  a  delicate  fibrous  stroma.  Though  these  areas  were  vascular, 
they  were  too  much  degenerated  to  allow  a  definite  conclusion  as  to  the  nature 
and  origin  of  the  cells.  In  general,  these  areas  resembled  inflammatory  cellular 
infiltration,  and  such  they  may  have  been. 

glio-sarcoma  and  round-celled  sarcoma. 

Fig.  53  (Case  820). — This  drawing  represents  a  section  from  the  most  cellular  por- 
tion of  the  tumor,  which  I  have  called  a  glio-sarcoma.  Several  capillary  vessels 
are  seen,  as  the  growth  is  very  vascular.  The  cells  are  seen  to  vary  extremely 
in  size  and  shape,  and  are  arranged  in  groups,  probably  having  some  relation  to 
the  blood  vessels.  The  cell  bodies  can  rarely  be  distinguished.  The  intercellu- 
lar substance  is  granular,  with  a  few  fibers  running  through  it.  It  much  resem- 
bles the  gray  matter  of  the  brain  in  the  sections.  In  view  of  the  recent  opinions 
as  to  the  origin  of  the  neuroglia  it  may  not  be  strictly  correct  to  use  the  term 
glio-sarcoma,  though  the  great  number  of  small  cells  with  evident  relation  to 
the  blood  vessels  suggests  the  presence  of  both  mesodermic  and  ectodermic  ele- 
ments. It  may  perhaps  be  better  to  regard  such  growths  as  combination  tumors 
resulting  from  hyperplasia  of  both  components  of  the  neuroglia.  This  tumor 
presented  the  gross  characteristics  of  glioma.     (PI.  XIX.) 


GOVERNMENT    HOSPITAL    FOR   THE    INSANE.  15 

Fig.  54  {Case  1237). — Round-celled  sarcoma  of  brain.  The  drawing  represents  the 
general  structure  of  the  growth  selected  from  many  sections  examined.  The 
cells  are  round,  uniform  in  size,  and  the  nuclei  nearly  rill  the  cells,  so  that  the 
surrounding  protoplasm  is  hard  to  distinguish  and  is  therefore  not  represented 
in  the  drawing.  The  intercellular  substance  is  scanty  and  apparently  granular, 
but  a  few  delicate  fibers  are  occasionally  seen.  Numerous  sections  of  blood  ves- 
sels, with  walls  composed  of  endothelium  and  a  few  delicate  fibers,  are  shown 
in  the  drawing.  The  vascularity  of  the  growth  and  the  grouping  of  the  cells 
around  the  vessels  suggest  angio-sarcotna,  or  at  least  some  relation  of  cell  devel- 
opment to  the  vessels,  though  in  other  respects  it  is  simply  a  vascular,  small, 
round-celled  sarcoma. 

Fig.  55  (Case  1231). — This  is  a  low-power  view  to  show  the  advancing  edge  of  the 
same  tumor  as  it  encroached  upon  the  white  substance  of  the  hippocampus.  In 
this  tumor  there  seemed  to  be  little  tendency  to  infiltrate  the  tissues  in  advance 
of  the  tumor,  but  rather  to  gradually  replace  the  invaded  tissue  as  the  growth 
grew.  In  the  drawing  the  tumor  tissue  is  shown  advancing  along  the  adventitia 
of  a  small  artery,  which  could  be  traced  for  some  distance  into  the  sarcomatous 
tissue. 

Fig.  56  (Case  1237). — The  field  represented  in  this  drawing  shows  the  border  of  the 
sarcomatous  growth  at  its  junction  with  a  band  of  connective  tissue,  such  as  are 
found  in  certain  parts  of  the  tumor  in  the  vicinity  of  the  pia  mater.  As  there  is  no 
tendency  of  the  tumor  structure  to  develop  into  fibrous  tissue,  I  think  it  probable 
that  these  areas  of  fibrous  connective  tissue  are  derived  from  the  included  pia 
mater  and  are  not  an  essential  part  of  the  growth.  The  drawing  is  intended 
mainly  to  show  two  concentrically  striated  calcareous  nodules  lying  within  the 
connective  tissue  at  the  border  of  the  new  growth.  These  bodies  were  very 
numerous  in  the  most  degenerate  portions  of  the  growth,  and  were  found  among 
the  remnants  of  connective  tissue  and  not  among  the  cells.  I  have  not  been 
able  to  trace  the  origin  of  these  bodies  to  alterations  in  the  cells,  and  have  con- 
cluded that  they  are  essentially  different  from  the  hyaline  and  calcareous  spherules 
which  occur  in  certain  spindle-celled  sarcomata  of  the  cranial  cavity  such  as 
studied  in  case  1146,  fig.  12.  They  are  commonly  lobulated  or  mulberry-like;  they 
do  not  show  traces  of  nuclei;  are  highly  retractile,  and  they  are  found  in  situa- 
tions where  there  is  no  disposition  of  the  cells  to  form  globular  aggregations  and 
to  undergo  hyaline  change.  They  are  supposed  to  be  identical  with  the  calcified 
granules  found  normally  in  the  pineal  gland  and  choroid  plexus,  known  as  brain 
sand  (acervulus  cerebri),  and  if  so,  they  are  different  in  origin  from  the  hyaline 
and  calcified  cell  spherules  of  the  spindle-celled  endothelial  sarcomata  studied  in 
this  and  former  reports,  though  the  two  are  commonly  confused  by  observers  on 
account  of  the  resemblance  between  them. 

pituitary  adenomata. 

Fig.  57. — Section  of  normal  adult  pituitary  body,  showing  the  different  kinds  of 
epithelium  in  the  acini  and  the  arrangement  of  the  cells.  In  some  of  the  cells 
are  globules  of  colloid  material. 

Fig.  58.— ^Section  of  normal  pituitary  body  showing  columnar  cells  imperfectly  lining 
the  acini,  etc. 

Fig.  59. — Section  from  the  pituitary  body  near  the  junction  of  the  anterior  and  pos- 
terior lobes.  Duct-like  structures  lined  with  columnar  cells  and  filled  with 
granular  colloid  material,  and  large,  clear,  rounded  cells  contained  in  small 
alveoli  are  represented.  Figs.  57,  58,  and  59  are  introduced  to  compare  with  the 
sections  of  the  adenoma  of  the  pituitary  body  found  in  case  788. 

Fig.  60  (Case  788). — This  section  is  from  the  denser  part  of  the  adenoma  of  the 
pituitary  body  where  the  acinous  arrangement  is  most  perfect.  The  connective 
tissue  septa  carry  the  blood  vessels  and  are  covered  by  a  more  or  less  perfect  layer 
of  columnar  cells.  Small  papillary  outgrowths  are  seen  to  arise  from  some  of  the 
walls  of  the  acini,  and  three  transverse  sections  of  similar  processes  are  seen  in 
the  large  acini.  The  central  portions  of  the  acini  are  filled  with  rounded  and 
polygonal  cells  without  any  indication  of  central  cavity. 

Fig.  61  ( Case  788). — Section  from  the  acinous  portion  of  the  pituitary  adenoma  show- 
ing several  small  alveoli  and  a  duct-like  structure  lined  with  columnar  cells  and 
containing  granular  colloid  material.     Compare  with  fig.  59. 

Fig.  62  (Case  788). — Section  of  small  areas  found  in  the  pituitary  tumor,  where  the 
cells  are  large,  round,  with  clear  or  slightly  granular  protoplasm,  and  show  but 
a  trace  of  columnar  arrangement.     Compare  with  fig.  59. 


1(3  GOVERNMENT    HOSPITAL    FOR    THE    INSANE. 

Fig.  63  (Case  788). — Section  showing  the  general  structure  and  arrangement  of  the 
looser  portions  of  the  pituitary  adenoma.  The  papillary  outgrowths  are  cut  in 
every  direction,  showing  that  they  are  more  or  less  cylindrical  and  covered  by 
columnar  cells.  The  interpapillarv  spaces  are  sometimes  filled  with  loose  cells 
similar  to  those  filling  the  alveoli  in  the  denser  portions,  or  they  may  be  empty, 
or,  more  properly,  filled  with  fluid  during  life. 

Fig.  t54  (Cast  788Y.  High-power  view  of  some  of  the  papillary  processes  represented 
in  fig.  63.  The  central  fibrous  tissue  of  every  papilla  contains  a  blood  vessel. 
This,  and  the  section  from  which  fig.  63  was  drawn,  were  fixed  to  the  slide 
before  removing  the  infiltrating  material,  so  that  the  exact  relations  of  the 
elements  are  preserved. 

Fig.  65  (Case  870). — High-power  view  of  the  tumor  of  the  pituitary  body.  The 
drawing  represents  one  complete  alveolus  and  parts  of  three  others.  The  alveoli 
are  very  large;  one  of  the  smallest  is  shown  in  the  drawing.  The  long,  columnar 
cells,  curiously  modified  by  mode  of  growth  and  mutual  pressure,  are  seen  to 
form  an  almost  perfect  lining  to  the  alveolus,  and  appeal'  to  be  proliferating  and 
throwing  off  cells  to  fill  the  interior.  The  cells  which  fill  the  central  cavity  of 
the  alveolus  are  generally  rounded,  but  show  almost  every  conceivable  shape 
caused  by  mutual  pressure.  The  central  mass  of  cells  is  almost  always  sepa- 
rated from  the  parietal  layer  by  a  space  which  is  probably  the  result  of  shrink- 
age in  hardening.  Papillary  outgrowths  from  the  alveolar  walls  are  rarely  found 
in  the  portions  of  the  tumor  examined,  but  in  other  respects  the  structure  is 
practically  identical  with  the  adenoma  of  the  pituitary  body  represented  by 
fig.  60,  case  788.  The  alveolar  walls  are  composed  of  mature  connective  tissue 
well  supplied  with  blood  vessels. 


SEEIES  I.  SPINDLE-CELLED  ENDOTHELIAL  SAE00MATA. 

Of  the  twenty-eight  true  intracranial  tumors  studied  in  this  mono- 
graph no  less  than  seventeen  belong  to  the  class  of  growths  commonly 
called  endotheliomata,  but  which,  on  account  of  their  structure,  sup- 
posed cytogenesis  and  histogenesis,  the  writer  has  named  spindle-celled 
endothelial  sarcomata;  spindle  cells  being  the  predominating  t}Tpe  of 
elements,  and  the  endothelium  of  the  dura  mater  and  probably  the  soft 
membranes  being  the  origin  of  the  growths. 

These  tumors  can  not  be  classed  with  any  other  division  of  morbid 
growths,  consequently  they  must  be  placed  with  the  sarcomata  or  in  a 
class  by  themselves.  They  are  cellular  tumors  of  embryonic  character 
and  of  mesodermic  origin,  and  are  thus  naturally  placed  with  the  sar- 
comata, though  they  differ  in  many  important  particulars  from  the 
ordinary  sarcomas. 

They  commonly,  if  not  always,  arise  from  the  dura  mater  or  one  of 
its  extensions,  as  flat,  wart-like  tumors,  usually  of  small  size,  but  may 
reach  two  inches  or  more  in  diameter.  They  are  intimately  but  not 
firmly  attached  to  the  dura,  and  when  mechanically  detached  from  the 
membrane  leave  the  surface  slightly  roughened  but  usually  intact. 
The  fact  that  the  growths,  being  friable  and  soft,  are  easily  torn  from 
their  seat  of  origin  and  leave  the  membrane  apparently  nearly  normal, 
has,  I  think,  led  to  mistakes  as  to  the  derivation  of  some  tumors  of  this 
class,  the  slight  attachments  to  the  dura  being  mistaken  for  inflammatory 
adhesions. 

In  the  course  of  their  growth  the  dural  tumors  slowly  penetrate  the 
brain,  making  at  first  a  slight  depression  in  the  surface  without 
destruction  of  tissue.  As  they  increase  in  size  the}7  push  the  pia  mater 
and  cortex  in  front,  usually  become  incorporated  with  the  soft  mem- 
branes, and  when  of  considerable  bulk  produce  destructive  softening 
of  the  cortex  and  white  matter  in  the  vicinitv.     Sometimes  the  mem- 


GOVERNMENT    HOSPITAL    FOE   THE    INSANE.  17 

branes  and  cortex  are  destroyed  to  such  a  degree  that  the  growth 
seems  to  directly  invade  the  white  matter,  and  large  tumors  lying 
within  the  brain  with  relatively  small  dural  surface  may  easily  be  mis- 
taken for  growths  of  the  pia  or  brain  substance. 

These  growths  are  usually  solitary,  but  in  two  or  three  of  my  cases 
more  than  one  nodule  was  found.  They  may  occur  at  any  part  of  the 
dura,  as  no  local  cause  appears  necessary.  The  bone  is  sometimes 
slightly  roughened  and  elevated,  and  the  dura  thinned  beneath  the  site 
of  the  tumor,  but  this  is  probably  the  effect  and  not  the  cause  of  the 
new  growth. 

These  tumors  do  not  invade  the  tissues  by  infiltration,  and  at  the 
same  time  no  distinct  capsule  can  be  demonstrated,  the  limiting  surface 
being  merely  a  condensation  of  the  peripheral  cell  elements  in  contact 
with  the  tissues  invaded.  Remnants  of  the  pia  mater  forced  in 
advance  of  tumors  penetrating  the  brain  have  been  mistaken  for  a 
connective-tissue  capsule,  but  no  such  tissue  is  found  on  the  free  sur- 
face of  the  smaller  dural  nodules.  The  growth  is  evidently  slow,  and 
they  do  harm  by  mechanical^  invading  the  brain;  they  are  sharply 
circumscribed,  and  when  penetrating  the  brain  in  regions  of  known 
function  they"  may  be  accurately  located;  and,  if  accessible,  they 
should  be  removed  before  thej^  reach  great  size  and  seriously  damage 
the  brain. 

The  exact  histogenesis  of  these  tumors  is  in  many  cases  hard  to 
determine.  In  most  of  the  writer's  cases  a  dural  origin  was  highly 
probable,  and  in  two  growths  of  the  series  there  was  unmistakable 
evidence  that  the  tumor  cells  originated  from  the  proliferated  endo- 
thelial cells  covering  the  arachnoid  villi  penetrating  the  parasinoidal 
and  lymph  spaces  of  the  dura  in  the  vicinity  of  the  falx  cerebri. 
The  evaginations  of  the  arachnoid  carry  with  them  the  endothelial 
layer  of  the  surface,  and  push  in  advance  the  endothelial  and  sub- 
endothelial  layers  of  the  dura  mater,  the  two  cell  layers  being  in 
microscopic  contact.  In  the  tumors  in  question  it  seemed  to  be  chiefly 
the  arachnoid  endothelium  that  showed  active  proliferation  and  entered 
into  formation  of  the  new  growths.  Over  some  of  the  arachnoid  villi 
the  cells  were  seen  to  be  several  layers  thick,  at  first  rounded  or 
polygonal  from  mutual  pressure,  and  finally  becoming  elongated  and 
spindle  shaped  as  they  extended  in  long  cell  processes  to  join  the  main 
tumor  mass  at  the  necks  of  the  villi.  The  peculiar  tendency  of  the 
tumor  cells  to  arrange  themselves  into  concentric  groups  and  to 
undergo  hyaline  change  was  manifested  while  they  yet  occupied  the 
arachno-dural  interspaces.  Some  cell-spherules  and  hyaline  bodies 
were  found  within  these  narrow  channels,  as  shown  in  fig.  41,  case  278. 

The  structure  of  these  growths  varies  somewhat  in  individual  cases, 
but  a  general  description  would  answer  for  most  tumors  of  the  class. 
They  are  made  up  for  the  most  part  of  delicate,  slender  spindle  cells, 
with  elongated  oval  nuclei  and  clear  cell-bodies.  In  the  denser  spindle- 
cell  portions  the  cells  are  closety  applied  to  each  other  without  dis- 
tinguishable intercellular  substance,  and  the  tissue  much  resembles 
richly  nucleated  fibrous  tissue,  as  it  is  extreme^  difficult  to  differentiate 
individual  cells.  In  other  growths  and  even  in  other  portions  of  the 
same  tumor,  there  ma,j  be  a  more  or  less  abundant  fibrillated  inter- 
cellular matrix,  which  doubtless  has  led  to  the  description  of  such 
varieties  as  fibromata. 

24648— 03-^ — 2 


18  GOVERNMENT    HOSPITAL    FOR    THE    INSANE. 

Examination  of  the  developing  borders  of  those  growths  shows  that 
the  cells  are  at  first  rounded  or  polygonal,  and  that  the  spindle  shape 
is  a  later  stage  of  development.  In  some  tumors  many  of  the  cells 
remain  embryonic  and  endothelioid,  sometimes  arranged  in  groups 
with  a  spindle-celled  stroma  forming  an  alveolar  structure.  In  this 
respect  these  tumors  do  not  differ  materially  from  ordinary  spindle- 
celled  sarcomata  of  the  endothelial  type. 

In  some  tumors  connective  tissue  is  present  in  considerable  amount, 
sometimes  forming  alveoli,  in  which  lie  groups  of  variously  arranged 
spindle  cells.  In  some  cases  the  fibrous  tissue  forms  broad  bands 
running  in  every  direction  through  the  tissue  and  carrying  the  prin- 
cipal blood  vessels;  again  this  tissue  may  be  scanty  and  ma}T  be  mainly 
resolved  into  spindle  cells  and  delicate  fibrils,  apparently  the  transition 
stage  between  the  spindle-cell  tissue  and  the  more  mature  connective 
tissue. 

The  blood-vessel  walls  are  mainhT  composed  of  an  endothelial  intima, 
with  a  more  or  less  thick  fibrous  investment.  In  the  most  cellular 
portions  the  walls  are  usually  thin,  being  composed  of  an  endothelial 
coat  with  a  few  connective-tissue  fibrils  arranged  both  circularly  and 
longitudinally.  In  some  tumors  the  vessels  are  often  surrounded  with 
many  layers  of  circularly  disposed' spindle  cells,  apparently  identical 
with  the  tumor  elements.  Hyaline  degeneration  is  very  common  in 
the  walls  of  the  vessels,  affecting  both  fibrous  tissue  and  spindle  cells; 
and  occasionally  the  walls  are  greatby  thickened  and  the  lumen  nearly 
or  quite  obliterated.     See  figs.  24-31. 

Though  these  tumors  differ  in  many  respects  from  the  ordinary  sar- 
comata, they  belong  to  the  connective-tissue  group  of  new  growths, 
and  we  must  regard  both  the  blood  vessels  and  the  connective  tissue 
as  essential  parts  of  the  structure.  We  find  also  in  these  growths  as 
in  ordinary  sarcomas,  the  tendency  to  develop  from  the  embiyonic  to 
the  more  mature  forms  of  mesoblastic  tissue. 

In  all  tumors  of  this  class  there  is  a  marked  tendency  for  the  cells 
to  arrange  themselves  into  whorls,  or  concentrically  grouped  cell 
spherules  separated  from  each  other  by  longitudinal  groups  of  spindle 
cells.  These  groups  are  often  further  separated  into  large  alveoli  by 
connective-tissue  septa,  as  seen  in  tig.  4. 

The  cause  of  this  peculiar  mode  of  growth  can  not  be  wTell  explained. 
It  may  possibty  be  due  to  cell  development  from  certain  centers,  the 
peripheral  layers  being  flattened  into  spindle  shapes  b}r  pressure.  It 
ma}^  also  be  related  to  the  early  development  of  the  cells  from  the  con- 
nective-tissue lymph  spaces  or  the  endothelium  of  the  lymph  vessels. 
So  far  as  I  know  this  peculiarity  of  cell  growth  is  confined  to  tumors 
of  the  dura  mater  and  possibly  of  the  soft  membranes,  so  that  it  may 
depend  upon  some  histogenetic  factor  not  yet  explained. 

Some  of  the  concentrically  arranged  cell  masses  contain  distinct  cen- 
tral groups  of  round  endothelioid  cells  surrounded  by  several  layers  of 
spindle  cells.  In  the  apparently  older  cell  spherules  the  endothelioid 
cells  are  less  evident,  and  those  remaining  have  frequently  become 
hyaline. 

In  some  tumors  large  groups  of  endothelioid  cells  unchanged  into 
spindle-shape  remain  in  certain  fields;  but  in  such  there  are  always 
some  spindle  elements  which  give  character  to  the  growth  (fig.  38). 

These  tumors  are  peculiarly  liable  to  hyaline  degeneration,  and  sub- 
sequent calcification.     It  may  affect  the  cell  spherules,  the  spindle-cell 


GOVERNMENT   HOSPITAL    FOR   THE    INSANE.  19 

bands,  the  vessel  walls,  the  connective  tissue  present,  and  hyaline 
material  may  even  exist  as  small,  free,  concentrically  striated  globules 
in  the  vicinity  of  the  blood  vessels  and  elsewhere,  as  seen  in  fig.  31. 
When  affecting  the  concentric  cell  groups,  it  produces  the  peculiar 
hyaline  spherules  for  which  these  tumors  are  noted;  in  the  longitudinally 
disposed  bands  of  cells  it  forms  the  cylindrical  and  lanceolate  deposits 
found  in  some  tumors;  in  the  vessel  walls  it  results  in  great  thickening 
and  even  obliteration  of  the  lumen;  and  in  the  connective  tissue  it  con- 
verts whole  fields  into  glassy,  almost  structureless,  tissue,  with  a  few 
persistent  nuclei. 

It  is  the  object  of  the  arrangement  of  the  drawings  and  cases  to 
show  the  gradual  retrogression  of  the  cell  groups  into  the  hyaline 
and  often  calcified  spherules  and  lanceolate  deposits  which  have  led 
to  the  improper  use  of  the  term  psammoma  for  such  tumors. 

The  writer  is  convinced  that  the  hyaline  globes  originate  in  the 
degeneration  of  the  cell  groups  and  that  the  hyaline  and  calcified 
rods  are  of  the  same  nature.  The  degeneration  begins  in  the  center 
of  the  cell  groups,  probably  from  malnutrition  of  the  central  cells  as 
these  masses  are  avascular;  it  proceeds  outward  until  it  may  involve 
the  whole  group,  though  commonly  a  few  layers  of  peripheral  elements 
remain  unaffected.  The  greatest  degree  of  change  converts  the  cell 
group  into  a  faintly  concentrically  striated  spherule,  sometimes  calci- 
fied in  the  center  with  only  the  flattened  remnants  of  nuclei  to  show 
the  former  cell  structure. 

It  is  the  writer's  opinion,  based  upon  the  study  of  a  number  of 
these  tumors,  that  these  hyaline  and  sometimes  calcified  spherules 
should  be  clearly  distinguished  from  the  somewhat  similar  calcified 
bodies  which  are  frequently  found  in  the  pineal  gland,  choroid  plex- 
uses, degenerated  products,  and  growths;  and  are  known  as  "brain 
sand;"  and,  that  to  call  tumors,  such  as  above  described,  psammomata, 
acervulomata,  etc.,  is  incorrect. 

Though  these  tumors  must  be  placed  in  the  general  class  with  the 
sarcomata  they  are  not  malignant  in  the  usual  sense  of  the  term. 
They  seem  to  have  no  tendency  to  invade  the  adjoining  tissue  by  infil- 
tration, apparently  increasing  in  size  by  interstitial  cell  growth  as  a 
mass.  On  this  account  they  are  frequently  much  smaller  at  their 
dural  attachment  than  the  part  within  the  brain.  The  study  of  the 
origin,  the  mode  of  growth,  and  the  histology  of  these  peculiar 
growths  leads  to  the  conclusion  that  such  tumors  when  accessible 
may  be  removed  with  the  assurance  that  there  will  be  no  recurrence 
in  situ,  and  that  the  brain  lesion,  if  not  too  great,  may  be  repaired 
with  the  preservation  of  life  and  reason. 

CASE    853. 

SPINDLE-CELLED    SARCOMA    OF   BRAIN. 

C.  S. ;  aged  73  years;  married;  laborer;  late  soldier;  nativity,  Ger- 
many. Mental  disease,  senile  dementia;  duration  over  three  and  a 
half  years.  The  degree  of  dementia  was  great;  memory  was  bad;  sight 
and  hearing  impaired;  general  muscular  feebleness,  but  no  distinct 
paratysis.  There  was  a  history  of  occasional  vomiting,  which  may  or 
may  not  have  been  of  cerebral  origin,  but  with  this  exception  the  usual 
S3Tmptoms  of  intracranial  tumor  were  absent,  and  the  above  mental  and 


20  GOVERNMENT    HOSPITAL    FOR   THE    INSANE. 

physical  symptoms  wore  attributed  to  senility.  The  patient  sank  grad- 
ually and  died  of  exhaustion  and  diarrhea. 

Autopsy  twenty-one  hours  after  death.  Body  showed  some  emacia- 
tion; rigor  mortis  passing  off. 

Orcmium. — Skull  rather  thick  and  dense;  sutures  nearly  obliterated. 
Shape  almost  symmetrical;  antcro-posterior  diameter  7^  inches;  trans- 
verse, tii  inches.  The  dura  mater  was  generally  slightly  thickened  and 
was  firmly  adherent  to  the  bone.  Over  the  inner  surface  of  both  sides 
was  a  thin  false  membrane  of  internal  pachymeningitis,  and  on  the  right 
side  over  the  parietal  region  were  three  small  nodules  of  whitish  tissue 
which  projected  inward.  The  falx  major  was  considerably  thickened 
generally,  and  about  its  middle  were  several  nodules  similar  to  those 
above  described,  but  of  larger  size.  The  falx  was  more  firmly  adherent 
to  the  pia  mater  in  the  vicinity  of  these  growths  than  elsewhere,  and 
the  pia  was  torn  by  its  removal.  None  of  the  small  dura]  growths  were 
large  enough  to  press  injuriously  upon  the  brain,  as  they  wTere  flat  in 
shape,  and  the  largest  did  not  project  over  one-fourth  of  an  inch  above 
the  general  surface  of  the  membrane. 

Brain:  Weight  of  right  hemisphere,  20f  ounces  (588.26  grams);  left 
hemisphere,  20i  ounces  (574.08  grams);  cerebellum,  pons,  and  medulla, 
Bounces  (170.10  grams).  Pia  mater  slightly  opaque;  arteries  at  base 
of  brain  atheromatous,  distorted,  and  irregularly  dilated.  Convolu- 
tions were  atrophied  over  the  whole  brain,  but  somewThat  less  so  at  the 
base.  By  palpation  a  hard  mass  was  found  in  the  right  hemisphere  at 
the  junction  of  the  temporal  and  occipital  lobes.  Section  revealed  a 
tumor  in  the  white  matter  about  If  inches  in  diameter  and  nearly 
globular  in  shape.  A  section  made  at  right  angles  to  the  long  axis  of 
the  hemisphere  and  about  half  an  inch  posterior  to  the  splenium  of  the 
corpus  callosum,  passed  through  the  center  of  the  tumor. 

On  superficial  examination  the  tumor  appeared  to  have  originated 
in  the  white  matter,  as  it  seemed  to  be  at  no  place  in  contact  with  the 
cortex  or  pia  mater.  At  the  posterior  portion  of  the  lateral  ventricle 
the  growth  was  only  separated  from  the  cavity  lry~  the  thickened  epen- 
dyma, and  in  the  descending  horn  the  choroid  plexus  was  adherent  to 
the  ependyma  and  the  hardened  exterior  of  the  tumor.  A  small  white 
fimbriated  body  seemed  to  extend  from  the  wall  of  the  tumor  into  the 
descending  eornu  and  to  become  adherent  to  the  choroid  plexus.  It 
was  quite  similar  in  texture  and  appearance  to  the  thickened  epen- 
dyma and  may  have  been  the  corpus  fimbriatum  altered  by  inflamma- 
tory changes.  The  proximity  of  the  growth  to  the  ependyma,  choroid 
plexus,  falx,  and  tentorium,  and  the  presence  of  similar  growths  on 
the  dura  mater,  suggest  that  the  tumor  probably  originated  from  the 
membranes  rather  than  from  the  brain  substance. 

The  growth  encroached  upon  the  gyrus  fornicatus  and  the  hippocam- 
pal  convolution  from  within,  but  there  were  no  evidences  of  pressure 
externally  and  no  signs  of  increased  intracranial  tension. 

The  tumor  appeared  to  be  sarcomatous  in  its  nature.  It  was  firm, 
granular  on  section,  reddish  gray  in  color,  and  seemed  to  be  separated 
from  the  brain  substance  by  a  condensed  exterior  or  an  imperfect  cap- 
sule. In  the  center  was  a  small  hard  mass,  which  could  not  be  cut  with 
the  knife,  probably  a  calcified  portion,  and  small  gritty  granules  were 
distinguished  throughout  the  growth.  The  brain  tissue  in  the  vicinity 
of  the  tumor  was  extremly  soft,  so  that  it  was  difficult  to  keep  the 
growth  in  place  while  making  the  sections  through  it.     To  the  naked 


GOVERNMENT    HOSPITAL    FOR    THE    INSANE.  21 

eye  the  dural  tumors  appeared  similar  to  the  cerebral  growth  in 
consistence  and  composition. 

On  the  left  side  a  softening  involved  the  head  of  the  caudate  nucleus 
and  extended  slightly  into  the  internal  capsule;  the  lenticular  nucleus 
was  full  of  small  brown  softenings  and  there  was  extensive  softening  of 
the  optic  thalamus.  On  the  right  side  there  was  a  small  softened  area 
in  the  head  of  the  caudate  nucleus  and  several  in  the  thalamus  and 
lenticular  nucleus.  The  general  consistence  of  the  brain  tissue  was 
reduced.;  perivascular  spaces  enlarged.  No  tumor  deposits  or  other 
gross  lesions  were  found  in  the  cerebellum,  pons,  and  medulla. 

Thorax.—  Pleural  cavities  normal.  Weight  of  left  lung,  27  ounces 
(765.45  grams);  right  lung,  28£  ounces  (807.97  grams).  Anterior 
margins  emphysematous;  posterior  portions  were  engorged  and 
cedematous. 

Heart:  Weighty  13  ounces  (368,55  grams).  Pulmonary  valves  nor- 
mal; tricuspid  valve  admitted  four,  ringers,  but  was  otherwise  normal. 
Aortic  valves  much  thickened  and  rigid;  mitral  valve  greatly  thick- 
ened at  its  margins.  Heart  cavities  slightly  dilated  and  the  walls 
flabby  and  relaxed.  The  aorta  was  somewhat  atheromatous  at  its  upper 
part  and  the  abdominal  portion  was  much  diseased. 

Aldomen. .—The  spleen  weighed. 7f  ounces  (219.71  grams);  capsule 
wrinkled  and  thickened  in  patches;  pulp  very  soft. 

Kidneys,:  Weight  of  each,  4  ounces  (113.40  grams).  Capsules  not 
adherent;  surfaces'  smooth;  some  increase  of  pelvic  fat.  Urinary 
bladder  normal.  ... 

Liver:  WTeight,  47  ounces  (1,332.45  grams).  Tissue  normal,  except 
some  post-mortem  softening.  Gall-bladder  contained  about  2  ounces 
of  dark  bile.  .    . 

Other  abdominal  organs  showed  no  signs  of  disease. 

MICROSCOPICAL   EXAMINATION. 

Tumor:  The  tumor  consisted  mainly  of  delicate  spindle  cells  arranged 
in  wavy  bands  and  whorls,  which  were  found  without  definite  order 
throughout  the  growth.  The  individual  spindle  Cells  were  slender, 
more  or  less  wavy',  with  elongated  oval  nuclei  which  stained  with  great 
brilliancy  in  ruclear  stains,  while  the  cell  bodies  remained  nearly 
unstained.  In  some  portions  of  the  growth  the  cells  were  separated 
by  a  variable  quantity  of  faintly  fibrillated  intercellular  substance, 
giving  a  looser  appearance  to  the  tissue;  in  other  places  the  cells  were 
densely  packed  and  arranged  in  definite  bands  arid  cell  whorls.  A 
little  connective  tissue  was  sometimes  found  between  the  denser  cell 
masses,  and  blood  vessels  were  found  occasionally  in  the  connective 
tissue  and  also  in  the  midst  of  the  cell  masses.  A  few  of  the  larger 
blood  vessels  showed  thickened  hyaline  walls;  the  capillary  blood 
channels  had  more  or  less  distinct  walls,  and  ran  in  every'  direction 
through  the  cell  masses. 

A  few  of  the  concentrically  arranged  groups  of  cells  showed  com- 
mencing" hyaline  change  in  their  central  portions,  and  in  some  parts  of 
the  tumor  hyaline  spherules  were  numerous.  They  usually  showed 
distinct  lamination,  and  in  almost  all,  flattened  elongated  nuclei  were 
distinguishable  between  some  of  the  lamina?,  suggesting  their  origin 
from  the  cell-whorls.  Many  of  the  hyaline  bodies  showed  many  layers 
of  concentrically  arranged  spindle  cells  around   them.     Some  were 


22  GOVERNMENT    HOSPITAL    FOR    THE    INSANE. 

partly  calcified  in  their  centers,  but  the  section  knife  usually  passed 
through  them  when  they  lay  in  the  plane  of  the  section. 

In  some  parts  of  the  tumor  it  seemed  that  the  bands  of  cells  had 
become  hyaline  in  their  centers,  and  coiled  and  interlaced  hyaline 
cylinders  lay  among-  the  cells.  The  exact  nature  of  these  hyaline 
structures  could  not  be  determined. 

In  limited  fields  of  some  sections  groups  of  rounded  endothclioid 
cells  were  found  lying  among  the  fasciculi  of  spindle  cells.  They 
were  undoubtedly  polygonal  in  shape,  with  round  nuclei,  and  were 
easily  distinguished  from  transverse  sections  of  spindle  cells.  To 
growths  showing  a  predominance  of  such  cells  the  name  endothelioma 
is  given,  but,  as  in  this  case,  the  main  bulk  of  the  growth  was  com- 
posed of  spindle  cells,  it  may  be  regarded  as  a  spindle-cell  sarcoma, 
probably  of  endothelial  origin. 

Sections  from  the  peripheral  portions  of  the  growth  showed  an 
imperfect  capsule  of  connective  tissue  which  limited  the  tumor,  and 
there  was  no  infiltration  of  the  brain  substance.  The  origin  of  the 
growth  could  not  be  determined  by  the  microscopical  examination,  but 
its  exact  resemblance  to  the  dural  tumors  studied  in  other  cases,  and 
the  resemblance  to  the  small  growths  found  on  the  dura  in  the  same 
case,  suggest  that  it  may  have  originated  from  the  dura  mater  at  some 
point  not  discovered. 

The  small  tumors  in  the  dura  mater  were  in  all  essentials  identical 
with  the  cerebral  growth  except  that  they  were  more  vascular. 

The  brain  showed  some  tortuosity  of  the  blood-vessels,  enlargement 
of  the  perivascular  and  pericellular  spaces  and  advanced  degeneration 
in  the  nerve-cells.  The  spinal  cord  seemed  normal.  The  other  organs 
showed  nothing  of  importance  in  addition  to  the  naked-eye  appearances. 

CASE  842. 

SPINDLE-CELLED    SARCOMA   OF    DURA   MATER. 

T.  K. ;  aged  67;  single;  late  soldier;  nativity,  Ireland.  Mental  dis- 
ease; chronic  dementia;  duration,  unknown.  This  patient  was  much 
demented  at  the  time  of  his  admission,  so  that  the  impairment  of  the 
special  senses  could  not  be  well  determined.  The  sense  of  smell  must 
have  been  destroyed,  and  sight  was  probably  impaired,  though  he  was 
not  blind.  He  was  restless  and  destructive,  but  he  was  confined  to  his 
bed  on  account  of  muscular  enfeeblement.  The  typical  s3^mptoms  of 
brain  tumor  were  not  present,  though  the  dementia  may  have  been  a 
symptom,  and  he  had  at  least  one  convulsive  attack,  which  occurred 
about  twenty-four  hours  before  his  death. 

Autopsy  twenty-one  hours  after  death.     Body  fairly  well  nourished. 

Cranium. — Antero-posterior  diameter,  7f  inches;  transverse,  5f 
inches.  Skull  asymmetrical,  the  left  side  being  the  larger,  and  the 
internal  occipital  protuberance  was  situated  to  the  right  of  the  median 
line.  The  frontal  bone  was  a  little  thicker  than  usual;  Pacchionian  and 
vascular  depressions  wide  and  deep;  diploe  congested;  sutures  partly 
obliterated.  The  dura  mater  was  generally  adherent  to  the  bone,  and 
over  the  inner  surface  at  the  vertex  was  a  thin  false  membrane  of 
internal  paclvymeningitis.  Over  a  small  area,  about  an  inch  posterior 
to  the  crista  galli,  corresponding  with  the  body  of  the  sphenoid  bone, 
the  surface  was  raised  into  a  rough  prominence  about  three -sixteenths 


GOVERNMENT    HOSPITAL    FOR    THE    INSANE.  23 

of  an  inch  above  the  level  of  the  bone.  At  this  situation  the  dura 
adhered  firmly  to  the  rough  surface,  and  the  inner  surface  of  the  mem- 
brane was  adherent  to  a  tumor  mass  which  was  imbedded  in  the  orbital 
surface  of  the  frontal  lobes.  The  dura  at  this  point  was  partly 
destroyed,  but  an  imperfect  layer  of  the  membrane  still  intervened 
between  the  tumor  and  the  bone.  The  olfactory  fosste  were  still  unaf- 
fected in  front  of  the  diseased  bone,  but  there  were  no  traces  of  the 
anterior  portions  of  the  olfactory  nerves. 

Brain:  Weight  of  right  half,  24£  ounces  (694.57  grams);  left  half, 
24  ounces  (680.40  grams).  In  the  orbital  surfaces  of  the  frontal  lobes 
was  a  large  tumor,  situated  in  the  median  line,  and  apparently  equally 
divided  between  the  two  hemispheres.  The  growth  measured  about 
2£  inches  in  diameter;  it  was  roughly  globular,  with  a  shallow  depres- 
sion in  its  under  surface  which  corresponded  with  the  elevation  on  the 
surface  of  the  bone.  The  tumor  appeared  to  have  originated  from  the 
dura  mater,  and  it  had  penetrated  the  brain  and  pushed  aside  and 
destroyed  the  structures  with  which  it  came  in  contact.  Over  the 
outer  portion  of  the  tumor  the  pia  mater  and  the  arachnoid  were 
tightly  stretched,  indicating  that  the  tumor  had  grown  lateral^  after 
penetrating  the  brain.  The  growth  extended  from  about  half  an  inch 
anterior  to  the  optic  chiasma  to  within  about  the  same  distance  from 
the  anterior  extremity  of  the  frontal  lobes.  The  anterior  portions  of 
the  olfactory  nerves  were  involved  in  the  tumor  growth  and  destroyed; 
their  posterior  portions  were  not  affected.  There  appeared  to  be  no 
pressure  upon  the  optic  nerves,  and  no  evidences  of  disease  were  visi- 
ble to  the  naked  eye.  • 

Incision  in  the  median  line  showed  that  the  growth  had  pushed  aside 
and  destroyed  the  convolutions  of  the  lower  part  of  the  median  surfaces 
of  the  frontal  lobes,  and  had  pressed  the  genu  of  the  corpus  callosum,  the 
anterior  cerebral  arteries,  and  the  septum  lucidum  upward  and  backward. 
The  orbital  convolutions  were  pressed  aside  and  destroyed,  but  the 
tumor  was  situated  too  far  anterior  to  encroach  upon  the  third  frontal 
convolutions  except  somewhat  upon  the  lower  portions. 

One- half  of  the  tumor  was  enucleated  from  its  depression  in  the 
brain  and  the  surface  was  found  to  be  rough,  somewhat  nodular,  and 
slightly  adherent  to  the  remnants  of  pia  mater  at  the  bottom  of  the 
depression.  There  appeared  to  be  a  distinct  fibrous  capsule,  probably 
remains  of  the  pia  mater,  in  which  large  blood  vessels  could  be  seen. 
The  falx  cerebri  extended  deeply  into  the  tumor  and  adhesions  had 
formed  on  both  sides  of  it. 

On  incising  the  tumor  the  knife  came  in  contact  writh  a  hard  calca- 
reous mass,  of  considerable  size,  which  required  the  use  of  the  bone 
forceps  to  cut  it  through.  The  growth  was  reddish-gray  in  color,  and 
punctiform  hemorrhages  could  be  seen  on  the  cut  surface.  The  con- 
sistence was  firm,  cut  surface  granular  in  appearance  and  dry. 

The  brain  tissue  in  the  vicinity  of  the  growth  was  very  soft,  and 
there  was  oedema  and  general  reduction  of  consistence  of  the  brain 
substance  and  enlargement  of  the  perivascular  spaces.  The  convolu- 
tions were  slightly  flattened  over  the  frontal  lobes;  there  was  some 
atrophy  over  the  convexity,  and  a  slighter  degree  in  other  regions. 
The  pia  mater  over  the  upper  portions  of  the  convexity  was  slightly 
opaque;  veins  engorged;  arteries  at  the  base  atheromatous  and  dis- 
torted; ventricles  slightly  encroached  upon  by  the  tumor  pressure; 
ependyma  normal. 


24  GOVERNMENT    HOSPITAL    FOR    THE    INSANE. 

The  cerebellum,  pons,  medulla  oblongata,  and  cervical  cord  showed 
nothing  of  especial  interest. 

Thorax.  —  Weight  of  right  lung,  213-  ounces  (701.66  grams);  left,  20 
ounces  (567  grams).  The  anterior  margins  were  emphysematous, 
and  the  posterior  portions  were  hypostatic.  Bronchial  glands  deeply 
pigmented. 

Heart:  Weight.  13  ounces  (808.55  grams).  Pulmonary  valves  very 
thin  and  easily  torn:  tricuspid  valve  normal;  aortic  valves  were  thick- 
ened, contracted,  and  at  line  of  contact  were  some  chronic  vegetations; 
margins  of  mitral  valve  somewhat  thickened;  heart  muscle  flabby, 
and  the  wall  of  the  right  ventricle  was  encroached  upon  by  the 
superficial  fat.  The  aorta  was  very  atheromatous  and  the  arch  was 
greatly  dilated. 

Abdomen. — The  spleen  weighed  5|  ounces;  capsule  wrinkled;  pulp 
dark  and  very  soft. 

Kidneys:  Weight  of  left,  5j  ounces  (148.83  grams);  right,  If  ounces 
(134.66  grams).  Capsules  easily  removed;  surfaces  smooth;  the  left 
contained  a  moderate-sized  C}'st,  otherwise  the  organs  seemed  normal. 
Urinary  Madder,  normal. 

Liver:  Weight,  46f  ounces  (1,325.36  grams).  Tissue  showed  slight 
passive  congestion.     Gall-bladder  contained  3  ounces  of  thick  bile. 

Stomach,  intestines,  and  other  abdominal  organs  were  normal. 

MICROSCOPICAL    EXAMINATION. 

The  tumor  is  in  every  essential  identical  with  the  one  found  in  case 
774.  The  spindles  are  exactly  the  same,  but  the  arrangement  into 
whorls,  or  cell-nests,  is  not  so  Conspicuous.  A  few  cell-nests  are  found 
in  every  field,  but  they  are  generally  small,  and  hyaline  globes  are 
rarely  found.  Bands  of  spindle  cells  run  in  every  direction,  so  they  are 
cut  in  every  possibly  way  in  the  sections.  The  blood  vessels  are  not 
numerous;  they  are  found  in  the  delicate  connective  tissue  which  inter- 
sects the  cell  groups,  and  sometimes  in  the  midst  of  the  spindle  cells. 

The  drawing  from  this  tumor  represents  longitudinal  and  transverse 
views  of  bands  of  spindle  cells.  The  distinction  between  the  individual 
cells  in  transverse  sections -is  very  difficult  when  the  cells  are  closely 
packed;  the  effect  is  that  of  a  homogeneous,  or  faintly  granular,  ground 
substance,  in  which  lie  the  small  round  transverse  sections  of  the 
nuclei  of  the  spindle  cells. 

The  nerve-cells  of  the  brain  are  excessively  pigmented,  granular, 
and  many  are  partially  disintegrated  at  their  margins.  The  pericel- 
lular and  perivascular  spaces  are  enlarged.  Many  of  the  small  vessels 
are  very  tortuous,  and  around  many  are  accumulations  of  leucocytes, 
blood  cells,  and  pigment.  This  condition  of  the  vessels  is  seen  every- 
where, but  it  is  especially  marked  in  the  vicinity  of  the  tumor.  Spider 
cells  are  found  in  the  outer  laj'er  of  the  cortex,  and  the  neuroglia  is 
coarsely  fibrous.  Near  the  tumor  the  tissue  shows  great  numbers  of 
spider  cells,  increase  of  nuclei,  and  other  evidences  of  irritation  of  the 
brain  tissue.  The  cerebellum,  pons,  and  medulla  show  nothing  of 
special  interest. 

In  the  examination  of  the  other  organs  nothing  of  importance  was 
found. 


GOVERNMENT    HOSPITAL    FOR    THE    INSANE.  25 

CASE  774. 
SPINDLE-CELLED    SARCOMA    OF    DURA    MATER. 

L.  H.;  aged  63;  widower;  late  soldier;  nativity,  Germany.  In  this 
case  there  were  many  of  the  symptoms  of  brain  tumor.  The  patient 
was  much  demented;  was  totally  blind;  had  convulsive  attacks,  and 
had  general  paralytic  symptoms,  but  without  distinct  paralysis.  Head- 
ache and  vomiting  were  not  marked  symptoms  during  his  stay  in  this 
hospital.  The  duration  of  the  mental  disease  was  given  as  three  years 
and  nine  months.  \ 

Autopsy  ten  hours  after  death.  Body  fairty  well  nourished;  bullet 
wound  on  outer  surface  of  right  thigh. 

Cranhwi. — Anteroposterior  diameter  of  skull,  7f  inches;  trans- 
verse, 6  inches.  Skull  thinner  than  usual  and  slightly  asymmetrical, 
the  right  side  being  unusually  prominent.  The  dura  mater  was  thicker 
than  normal,  and  adhesions  between  it  and  the  pia  mater  along  the 
median  edges  of  the  hemispheres  were  firmer  than  normal,  so  that  the 
removal  of  the  dura  brought  away  portions  of  the  pia  mater  with  it. 

Brain:  Weight  of  right  half,  27i  Ounces  (779.62  grams);  left  half, 
30  ounces  (85U.  50  grams).  A  large  globular  tumor  about  2£  inches 
in  average  diameter  occupied  the  basal  portions  of  the  frontal  lobes. 
The  tumor  had  apparently  originated  from  the  dura  mater,  as  it  was 
firmly  adherent  to  the  membrane  and  bone  over  an  area  of  about 
an  inch  and  a  half,  and  at  this  situation  the  dura  had  nearly  disap- 
peared and  the  bone  was  roughened  and  elevated.  The  tumor  had 
grown  almost  in  the  median  line  and  penetrated  the  frontal  lobes  as  a 
nearly  globular  mass,  the  larger  half  of  which  la}T  in  the  left  hemi- 
sphere. The  tumor  had  by  its  growth  into  the  brain  displaced  and 
destroyed  the  olfactory  nerves,  except  a  small  portion  of  their  roots; 
pressed  upon  and  involved  in  inflammatory-  adhesions  both  optic  nerves ; 
pushed  aside  and  destroyed  the  orbital  convolutions,  the  lower  convo- 
lutions of  the  median  surfaces  of  the  frontal  lobes,  the  anterior  por- 
tions of  the  third  frontal  convolutions,  and  had  pushed  the  anterior 
cerebral  arteries  and  the  genu  of  the  corpus  callosum  upward  and 
backward. 

The  growth  had  extended  laterally  in  the  left  hemisphere  so  that  it 
was  only  about  one-fourth  of  an  inch  beneath  the  surface  of  the 
anterior  part  of  the  third  frontal  convolution;  on  the  right  side  the 
corresponding  convolution  was  much  less  affected.  There  was  no 
appreciable  displacement,  of  the  basal  ganglia  and  the  insular  lobes, 
but  the  anterior  walls  of  the  ventricles,  the  lamina  cinerea,  anterior 
pillars  of  the  fornix,  and  septum  lucidium  were  crowded  backward  by 
the  pressure  upon  the  parts  in  front  of  them.  The  tumor  extended 
from  about  half  an  inch  anterior  to  the  optic  commissure  to  within 
half  an  inch  of  the  anterior  extremity  of  the  frontal  lobes. 

The  tumor  was  grayish  red  in  color,  firm,  and  was  granular  or  nod- 
ular on  the  surface.  Section  showed  the  interior  to  be  about  the  same 
color,  dry,  and  mottled  with  small  hemorrhagic  foci.  In  the  vicinity 
of  the  tumor  the  brain  substance  was  extremely  soft,  so  that  it  was 
difficult  to  keep  the  tumor  in  place  during  the  section  of  the  brain. 
The  tissue  seemed  to  have  been  to.  a  great  extent  absorbed  or  destroyed, 
but  the  tumor  was  circumscribed  by  an  imperfect  capsule  and  the 
brain  substance  was  not  infiltrated.  In  places  where  the  pressure  was 
not  so  great,  as  around  the  periphery  at  the  base,  traces  of  cortex  and 


26  GOVERNMENT   HOSPITAL    FOR    THE    INSANE. 

pia  mater  could  be  distinguished.  The  anterior  portion  of  the  falx 
was  adherent  to  the  tumor  by  inflammatory  adhesions,  but  was  not 
otherwise  involved  by  it. 

The  convolutions  generally  were  somewhat  flattened  against  the 
bone,  more  noticeably  over  the  frontal  lobes.  There  was  great  oedema 
in  the  vicinity  of  the  tumor,  and  the  brain  tissue  was  very  pale  and 
soft  for  some  distance  from  it;  the  consistence  elsewhere  was  slightty 
reduced,  and  the  perivascular  spaces  were  enlarged,  showing  chronic 
oedema  of  the  brain.  The  convolutions  showed  some  atrophy  over 
the  whole  brain.  The  section  showed  no  other  gross  lesions  in  the 
brain;  the  ventricles  were  not  dilated,  and  the  ependyma  was  smooth. 
The  arteries  at  the  base  showed  no  disease,  except  slight  atheroma  of 
the  intracranial  portions  of  the  carotids.  The  cerebellum,  pons,  and 
medulla  showed  no  gross  lesions. 

Thorax. — The  right  lung  weighed  24i  ounces  (687.48  grams);  the 
left,  15  ounces  (425.25  grams).  They  showed  a  slight  excess  of  blood, 
some  emphysema  of  anterior  margins,  some  old  pleural  scars,  and 
some  calcareous  nodules  at  the  apices. 

Heart:  Weight,  13  ounces  (368.55  grams).  An  opaque  patch  over 
anterior  wall  of  right  ventricle.  Pulmonaiy  valves  normal,  tricuspid 
orifice  slightly  enlarged;  aortic  valves  a  little  thickened;  mitral  valve 
thickened,  contracted,  and  some  vegetations  were  found  along  line  of 
contact.  The  chorda?  tendineae  were  thickened  and  shortened  so  that 
though  the  orifice  was  normal  in  measurement,  the  valve  was  probably 
incompetent.  There  was  slight  hypertrophy^  and  dilatation  of  all  the 
cavities. 

Abdomen. — Weight  of  spleen,  3i  ounces  (92.13  grams),  capsule 
adherent  to  the  structures  in  the  vicinity;  pulp  tough  and  fibrous. 

Kidneys:  Weight  of  left,  4i  ounces  (120.48  grams);  right,  4  ounces 
(113.40  grams);  capsules  easily  removed;  general  appearances  normal; 
urinary  bladder  normal. 

Liver:  Weight,  44£  ounces  (1,261.57  grams).  The  tissue  contained 
a  slight  excess  of  blood.  Gall-bladder  contained  an  ounce  of  bile  and 
one  rough  calculus. 

MICROSCOPICAL   EXAMINATION. 

The  tumor  is  composed  of  spindle  cells  with  oval  and  elongated  nuclei 
arranged  in  closely  packed  bands  and  whorls.  The  bands  of  cells  are 
found  to  run  in  every  direction  and  were  sectioned  at  all  angles  to  their 
course,  thus  giving  peculiar  appearances  in  different  parts  of  the  sec- 
tions. The  most  characteristic  arrangement  of  the  cells  is  the  forma- 
tion of  dense  whorls  or  circles  of  cells,  with  sometimes  one,  sometimes 
two  or  more  centers  around  which  the  cells  are  closely  applied.  These 
centers  of  cell-nests  are  surrounded  by  concentric  bands  of  cells  form- 
ing groups  or  lobules,  which  are  partlv  separated  from  each  other  by 
delicate  bands  of  connective  tissue.  The  appearance  of  the  cell-nests 
is  extremely  like  those  of  epithelioma,  but  whereas  the  "nests"  of  the 
epithelial  cancer  are  composed  of  squamous  cells,  which  appear  like 
spindle  cells  in  optical  section,  in  the  present  tumor  the  cells  are  with- 
out doubt  true  spindle  cells.  They  never  appear  as  squamous  cells, 
but  when  cut  in  transverse  direction  they  show  conclusively  that  they 
are  actual  spindles  with  elongated  nuclei.  Transverse  and  oblique 
sections  of  spindle  cells  are  seen  in  the  cell-whorls  showing  that  they 
are  applied  in  every  direction  around  the  centers.     In  the  center  of  the 


GOVERNMENT    HOSPITAL    FOR   THE    INSANE.  27 

cell-whorls  are  seen  several  nuclei  with  clear  or  faintly  granular  proto- 
plasm around  them.  I  have  not  been  able  to  resolve  this  protoplas- 
mic center  into  cells,  chiefly  because  it  seems  to  be  generally  more  or 
less  changed  into  hyaline  material,  but  I  think  it  reasonable  to  con- 
clude that  tihe  central  cells  of  the  cell-nests  are  spheroidal  or  polyhedral, 
as  they  undoubtedly  are  in  similar  cell  arrangements  in  closely  allied 
tumors.     See  case  1436,  fig.  5. 

A  few  laminated  hyaline  globules  are  found,  but  this  feature  is  not 
a  conspicuous  one  in  the  present  tumor.  Many  of  the  cell-nests  show 
the  tightly  packed  cells  and  glistening  protoplasm  in  their  centers, 
which  may  be  the  early  stages  of  hyaline  change. 

The  blood  vessels  are  not  numerous;  they  have  imperfectly  developed 
walls,  as  a  rule,  though  some  have  thick,  fibrous  walls,  and  some  are 
found  surrounded  by  a  few  layers  of  spindle  cells.  The  larger  vessels 
are  found  in  the  connective  tissue  bands  which  intersect  the  groups  of 
cells;  small  blood  channels  with  a  small  amount  of  adventitial  fibrous 
tissue  are  found  in  the  denser  masses  of  cells. 

Peripheral  sections  show  that  the  tumor  has  an  imperfect  fibrous 
capsule  containing  blood  vessels,  which  is  continuous  with  the  fibrous 
tissue  within  the  tumor.  The  looser  connective  tissue  in  the  tumor 
contains  many  spindle  cells  and  probably  is  of  similar  derivation. 

Nothing  of  special  interest  is  found  in  the  brain.  The  nerve-cells 
show  granular  degeneration  of  the  cell  bodies,  but  the  nuclei  are 
usually  well  preserved.  Some  of  the  cell  spaces  contain  only  clumps 
of  yellow  granules,  the  remains  of  degenerated  cells.  The  nerve  cells 
of  medulla  and  cord  show  an  excess  of  pigmentation.  The  kidneys 
show  slight  epithelial  degeneration.  The  other  organs  were  not  exam- 
ined with  the  microscope,  but  were  supposed  to  be  normal. 

SPINDLE- CELLED   ENDOTHELIAL   SARCOMA    OF  THE    DURA  MATER  AT  BASE 

OF   BRAIN. 

CASE   1436. 

J.  C. ;  aged  64;  married;  blacksmith;  late  soldier;  nativity,  New 
York.     Mental  disease,  chronic  dementia;  duration,  over  one  year. 

In  this  case  there  were  no  symptoms  of  intracranial  tumor,  the 
growth  being  small  and  having  not  encroached  upon  important  struc- 
tures. There  was  a  general  paralytic  condition  which  was  fully 
accounted  for  by  the  organic  disease  of  the  brain  found  post-mortem. 
The  patient  was  much  demented  and  could  not  well  describe  his  symp- 
toms, but  so  far  as  could  be  observed  had  no  pain  or  disturbance  of 
special  senses.  He  died  suddenly,  with  symptoms  of  apoplexy,  prob- 
ably induced  by  the  organic  disease  of  the  brain. 

Autopsy  twenty-two  hours  after  death.  Body  large  and  well  devel- 
oped; head  and  neck  deeply  congested;  hydrocele  of  right  side. 

Cranium. — Skull  symmetrical,  of  usual  shape  and  thickness. 
Antero-posterior  diameter,  7£  inches;  transverse,  5f  inches;  sutures 
visible  externally,  indistinct  in  inner  table;  arterial  depressions  well 
marked. 

The  dura  mater  was  adherent  to  the  bone,  of  usual  thickness,  and 
contained  a  small  osteophyte  in  the  falx. 

At  the  base,  resting  upon  the  anterior  clinoid  process,  was  a  small 
dural  tumor  about  half  an  inch  in  diameter  and  about  one-fourth  of 


28  GOVERNMENT    HOSPITAL    FOR    THE    INSANE. 

an  inch  in  thickness.  The  growth  was  tirmly  adherent  to  the  dura, 
incorporated  with  it.  and  evidently  had  originated  from  the  membrane. 
The  hone  was  slightly  roughened  beneath  the  tumor,  hut  though  the 
growth  was  in  close  relation  to  the  carotid  artery,  optic  nerve,  and 
cavernous  sinus,  it  had  not  pressed  upon  those  structures.  The  tumor 
was  grayish-red  in  color,  somewhat  rough  on  the  surface,  and  to  the 
naked  eye  resembled  the  common  form  of  dural  endothelioma. 

Brain:  Weight  of  left  hemisphere,  17<)  grams;  right  hemisphere, 
550  grams;  cerebellum,  pons,  and  medulla,  2Q0  grams.  The  tumor 
had  made  no  depression  in  the  brain  and  was  not  adherent  to  it.  The 
vessels  were  much  engorged;  subdural  fluid  tinged  with  blood;  arteries 
not  diseased.  The  convolutions  were  generally  shrunken,  and  on  the 
left  side  were  extensive  softenings,  involving  the  anterior  and  lower 
part  of  the  frontal  lobe,  the  anterior  portion  of  the  temporal  lobe,  and 
the  whole  island  of  Reil.  No  lesions  in  the  interior  nor  on  the  right 
side.  The  tissue  was  yellowish,  soft,  and  (edematous,  and  the  peri- 
vascular spaces  were  enlarged.  Cerebellum,  pons,  and  medulla  were 
in  the  same  general  condition  as  the  cerebrum,  but  showed  no  gross 
lesions. 

Thorax. — The  lungs  were  deeply  pigmented  with  carbon  and  hypo- 
static posteriorly.     "Weight  of  the  left,  550  grams;  right,  650  grams. 

Heart:  Weight,  470  grams.  Organ  flabby  and  soft;  auricles  and 
ventricles  dilated.  Right  valves  not  diseased ;  tricuspid  valve  relatively 
incompetent.  Aortic  valves  were  slightly  thickened  and  adherent  to 
each  other,  but  probably  fairly  competent.     Mitral  valve  normal. 

Ahdoimn. — Spleen  weighed  90  grams.  The  capsule  was  wrinkled 
pulp,  soft. 

Kidneys:  Weight  of  each,  200  grams.  Capsules  slightly  adherent; 
surfaces  granular  and  showed  numerous  small  cysts;  cortex  thin;  pyra- 
mids small,  and  the  pelvic  fat  was  increased.  Though  much  shrunken, 
the  weight  was  not  below  the  normal,  the  organs  having  been  original^ 
large. 

Liver:  Weight,  1,190  grams.  The  tissue  had  been  normal,  but  wras 
softened  b}7  decomposition. 

Other  organs  presented  nothing  of  importance. 

MICROSCOPICAL    EXAMINATION. 

The  tumor  was  found  to  belong  to  the  class  commonly  called  dural 
endotheliomata,  but  which  perhaps  are  better  designated  by  the  term 
spindle-celled  endothelial  sarcomata.  The  main  mass  of  the  growth 
was  made  up  of  delicate  spindle  cells,  with  oval  granular  nuclei  closely 
applied  to  each  other,  so  that  in  the  dense  masses  individual  cells  were 
hard  to  distinguish,  and  the  structure  of  the  tissue  was  mainly  recog- 
nized by  the  direction  and  shape  of  the  nuclei.  The  cells  were  arranged 
in  wavy  bands  running  in  eveiy  direction  and  in  concentrically  arranged 
groups,  which  are  a  characteristic  feature  in  tumors  of  this  class. 
These  cell  spherules  in  this  growth  seemed  to  consist  of  many  layers 
of  closely  applied  spindle  cells  surrounding  a  central  mass  consisting 
of  a  few  endothelioid  cells  sometimes  more  or  less  obscured  by  hyaline 
degeneration.  The  nuclei  of  these  central  cells  were  round  and  gran- 
ular, and  the  cell  bodies,  when  distinguishable,  were  large,  clear,  and 
rounded  when  not  closely  pressed  together.  A  feature  of  this  growth 
was  the  separation  of  the  cell  structure  into  lobules  by  thin  strands  of 


GOVERNMENT   HOSPITAL   FOR   THE    INSANE.  29 

fibrous  tissue  apparently  modified  from  the  spindle  cells.  In  these 
bands  the  blood  vessels  were  usually  found,  showing  more  or  less  dis- 
tinct fibrous  walls.  The  larger  vessels  were  found  in  the  fibrous  tissue, 
but  blood  channels  were  also  found  occasionally  in  the  cell  bands,  in 
this  situation  having  imperfectly  developed  walls.  Some  parts  of  the 
growth  were  unusually  vascular  for  tumors  of  this  class.  This  was 
.especially  noticeable  along  the  line  of  junction  with  the  dura.  No  per- 
fectly walled  blood  vessels  were  found  in  any  part  of  the  growth,  and 
none  of  any  kind  in  the  dense  cell-whorls. 

Hyaline  transformation  of  the  cell  groups  was  not  found  to  any 
extent.  Very  few  hyaline  globes,  so  commonly  found  in  this  class 
of  tumors,  were  discovered  in  the  present  growth,  though  the  central 
cells  of  some  of  the  cell  spherules  were  hard  to  stain  and  apparently 
becoming  hyaline.  A  large  tumor  of  the  dura  mater,  exactly  similar 
to  this  one  in  structure,  was  reported  in  the  supplement  to  the  report 
of  1894,  illustrated  in  this  work  by  PI.  IV  and  fig.  4,  case  774. 

The  microscopic  stud}^  of  the  kidneys  showed  advanced  interstitial 
nephritis.     Examination  of  the  other  organs  was  not  deemed  important. 

CASE  76. 

SPINDLE-CELLED    SARCOMA     OF     BRAIN,     PROBABLY    ORIGINATING    FROM 

THE    DURA   MATER. 

G.  C. ;  aged  73;  soldier;  nativity,  Germany.  Mental  disease, 
chronic  dementia,  duration  unknown.  The  symptoms  in  this  case 
can  not  be  given.  The  patient  was  profoundly  demented,  but  no 
other  symptom  of  intracranial  growth  was  observed.  The  clinical 
history  was  not  kept  at  the  time  and  can  not  now  be  recalled,  though 
from  the  situation  of  the  growth  very  interesting  effects  must  have 
been  present. 

The  growth  in  all  probability  originated  from  the  dura  mater  and 
penetrated  the  brain,  carrying  with  it  the  pia  mater.  Subsequent 
examination  of  growths  of  similar  character  has  convinced  me  that 
such  is  usually  the  case,  though  they  are  easily  torn  from  their  seat  of 
origin,  and  may  be  mistaken  for  cerebral  tumors  with  inflammatory 
adhesions  to  the  dura  mater. 

Autopsy  eleven  hours  after  death.  Body  short,  heavily  built,  and 
well  nourished.     Skin  showed  a  j^ellowish  tint. 

Cranhim. — Antero-posterior  diameter  of  skull,  6£  inches;  trans- 
verse, 5f  inches.  Skull  was  thicker  than  usual  and  the  dura  mater 
was  adherent  to  the  bone. 

Brain:  Weight,  41  ounces  (1,162.35  grams).  Pia  mater  opaque  and 
cedematous;  pial  veins  full  of  blood;  arteries  not  diseased.  The  con- 
volutions were  not  flattened  against  the  skull  and  there  were  no  signs 
of  increased  intracranial  tension,  the  atrophy  of  the  brain  being  suffi- 
cient to  permit  the  additional  bulk  of  the  tumor  without  general 
increase  of  pressure.  A  large  tumor  was  found  in  the  anterior  por- 
tion of  the  left  hemisphere  of  the  brain.  It  encroached  upon  the  pos- 
terior portion  of  the  orbital  convolutions,  the  anterior  portion  of  the 
temporal  lobe,  the  Island  of  Reil,  and  the  basal  ganglia  and  internal 
capsule.  These  structures  were  pressed  aside  and  in  part  destroyed 
by  the  growth  of  the  tumor  and  the  olfactory  and  optic  tracts  were 
involved  in  the  periphery  of  the  growth.  The  tumor  was  loosely  con- 
nected with  the  brain  substance,  so  that  it  was  hard  to  keep  it  in  place 


30  GOVERNMENT    HOSPITAL    FOR    THE    INSANE. 

during  the  dissection  and  subsequent  hardening.  It  seemed  to  have 
originated  from  the  dura  mater,  and  shreds  of  the  pia  mater  formed 
an  imperfect  capsule  around  the  growth.  The  tumor  was  a  dull  gra}T- 
ish  color,  moderately  soft  and  friable;  the  shape  was  nearly  globular, 
and  it  was  about  2  inches  in  its  greatest  diameter.  Nothing  unusual 
was  noted  in  other  parts  of  the  brain,  except  some  oedema  and  great 
reduction  of  consistence  in  the  immediate  vicinity  of  the  tumor. 

The  other  organs  showed  nothing  of  importance  in  relation  to  the 
intracranial  growth. 

MICROSCOPICAL   EXAMINATION. 

The  microscope  showed  the  tumor  to  be  a  spindle-celled  sarcoma,  in 
some  respects  peculiar  in  structure.  The  cells  were  small  spindles 
with  clear  cell  bodies,  which  stained  faintly  in  carmine,  and  distinct, 
granular,  elongated  oval  nuclei  which  stained  with  great  brilliancy. 
The  cells  were  arranged  in  closely  packed  bands  and  globular  or  oval 
whorls  or  cell  nests,  with  one  or  more  centers.  The  dense  cell  masses 
were  intersected  by  bands  of  looser  tissue,  composed  of  spindle  cells, 
delicate  connective  tissue,  and  blood  vessels.  Blood  vessels,  however, 
were  found  in  all  parts  of  the  tumor.  In  the  dense  cell  masses  they 
were  scanty  and  the  walls  were  imperfect;  in  the  looser  tissue  the}*- 
were  better  developed;  some  were  surrounded  by  several  layers  of 
.spindle  cells,  and  some  had  thick  hyaline-looking  walls  in  which  the 
cells  were  hard  to  distinguish. 

Scattered  through  the  tumor  were  peculiar  concentrically  laminated, 
spheroidal  or  oval  bodies  of  a  glistening,  hyaline  appearance,  which 
stained  faintty  in  carmine.  The}r  contained  one  or  more  centers  of 
lamination,  around  which  the  lamina?  were  arranged,  and  often  two  or 
more  of  these  centers  became  surrounded  by  a  common  capsule. 

These  hyaline  bodies  closely  resemble  the  cell  nests  in  size  and 
arrangement,  and  they  are  supposed  to  be  a  hyaline  transformation  of 
the  tightly  packed  cell  masses.  This  belief  is  strengthened  b}T  finding 
nuclei,  in  every  respect  resembling  those  of  the  cells,  in  the  center  of 
some  of  the  hyaline  bodies,  flattened  and  elongated  nuclei  between  the 
lamina?  of  some,  and,  finally,  all  intermediate  stages  between  the  cell 
nests  and  the  h}Taline  globes/' 

Jvote.— This  was  the  first  tumor  of  the  kind  studied  by  the  writer,  and  the  case 
was  reported  in  the  supplement  to  the  annual  report  of  the  hospital  for  1892.  The 
conclusions  as  to  the  nature  of  the  hyaline  spherules  have  been  verified  by  numerous 
observations  since  that  time. 

CASE  715. 
SPINDLE-CELLED    SARCOMA    OF   FALX    CEREBRI. 

F.  E. ;  aged  68;  single;  late  soldier;  nativity,  Germany.  This  patient 
had  none  of  the  symptoms  of  intracranial  tumor  except  dementia,  and 
this  was  evidently  not  due  to  the  presence  of  the  tumor,  as  the  growth 
was  on  the  dura  and  there  were  no  signs  of  pressure  or  other  effect 
upon  the  brain  except  the  depressions  noted  below.  His  mental  disease 
was  dementia,  without  marked  delusions  or  hallucinations.  The  dura- 
tion was  about  two  years  and  eight  months. 

«  An  excellent  description  of  a  tumor,  in  every  respect  similar  to  this,  will  be 
found  in  an  article  entitled  "Case  of  intracranial  tumor,"  by  Conollv  Norman,  F. 
R.  C.  S.  I.,  Journal  of  Mental  Science,  July,  1890. 


GOVERNMENT    HOSPITAL    FOR    THE    INSANE.  31 

Autopsy  five  hours  after  death.  Body  fairly  well  nourished;  large 
hydrocele  of  left  side. 

Cranium. — Antero-posterior  diameter,  7  inches;  transverse,  6  inches. 
Skull  rather  thinner  than  usual,  peculiar  in  shape,  and  asymmetrical; 
sutures  partly  obliterated;  small  nodular  exostosis  at  posterior  end  of 
sagittal  suture.  Dura  mater  moderately  adherent  to  the  bone.  On 
the  falx  cerebri,  about  half  an  inch  posterior  to  the  coronal  suture,  was 
a  small  reddish-gray  tumor  about  half  an  inch  in  diameter.  It  was 
situated  on  both  sides  of  the  falx,  a  little  more  on  right  side  than  on 
the  left,  and  the  falx  seemed  to  pass  directly  through  it.  The  growth 
was  somewhat  granular  on  the  surface,  and  section  showed  the  tissue 
to  be  a  of  reddish-gray  color  and  not  very  vascular.  The  superior  lon- 
gitudinal sinus  passed  through  the  tumor  without  any  obstruction  of 
its  lumen,  and  the  growth  did  not  extend  as  far  downward  as  the  infe- 
rior sinus.  Over  the  inner  surface  of  the  dura  of  left  side  was  a  thin, 
rust-colored  false  membrane  of  internal  pachymeningitis;  it  extended 
to  the  base,  but  did  not  involve  the  basal  portions. 

Brain:  Weight,  38|  ounces  (1,098.56  grams).  The  pia  mater  adhered 
slightly  to  the  surface  of  the  tumor,  so  that  the  membrane  was  torn 
in  removing  the  brain.  The  tumor  had  made  a  shallow  depression  on 
the  median  surface  of  the  right  first  frontal  convolution  and  the  ante- 
rior portion  of  the  paracentral  lobule.  The  depression  was  slight  and 
the  cortex  seemed  normal  within  it.  On  the  left  side  a  corresponding- 
depression  could  just  be  distinguished.  The  pia  mater  showed  some 
opacity  over  the  greater  part  of  the  convexity;  veins  moderately  full 
of  blood;  arteries  at  the  base  atheromatous,  distorted  and  irregular  in 
caliber,  and  recently  formed  thrombi  were  found  in  all  the  principal 
vessels.  The  convolutions  were  greatly  shrunken  and  indurated  over 
the  whole  brain;  the  parts  at  the  base  were  also  atrophied,  showing 
the  crura  and  other  structures  with  great  distinctness.  The  ventricles 
were  moderately  dilated;  the  ependyma  granular.  Brain  tissue  rather 
firm;  perivascular  spaces  enlarged;  cortex  very  thin  and  yellowish  in 
color. 

Thorax. — Pleuritic  adhesions  on  both  sides.  Right  lung  weighed  14 
ounces  (396.90  grams);  the  left,  20  ounces  (567  grams).  Some  pleural 
scars  at  the  apices  and  hypostasis  of  posterior  portions  of  both. 

Heart:  Weight,  11  ounces  (396.90  grams).  Pericardial  cavit}7  oblit- 
erated by  recent  fibrinous  adhesions.  Pulmonary  and  tricuspid  valves 
normal;  aortic  valves  were  greatly  thickened  and  contracted,  the  seg- 
ments just  admitting  the  tip  X>i  the  little  finger;  the  contiguous  edges 
of  the  segments  were  adherent  and  the  attached  edges  were  calcare- 
ous. The  mitral  valve  was  somewhat  thickened  at  its  free  borders, 
but  the  orifice  was  normal;  some  calcareous  deposits  were  found  at  the 
base  of  the  valve.  The  left  ventricle  was  somewhat  dilated;  the  wall 
of  the  right  was  encroached  upon  by  the  superficial  fat.  The  arch 
and  thoracic  portion  of  the  aorta  showed  atheroma  and  dilatation 
almost  amounting  to  a  fusiform  aneurism;  the  abdominal  aorta  was 
almost  free  from  atheroma. 

A hdomen.  —  Spleen:  Weight,  1  ounces  (113.10  grams);  capsule, 
wrinkled;  pulp,  tough  and  fibrous. 

Kidneys:  Weight  of  the  left  with  large  cyst,  13  ounces  (368.55 
grams);  with  cyst  emptied,  1  ounces  (113.10  grams);  weight  of  right, 
I  ounces  (113.10  grams).  The  left  contained  one  very  large  cyst;  the 
right  a  medium-sized  cyst.  Capsules  adherent;  surfaces  smooth;  cor- 
tex rather  thin;  pelvic  fat  abundant.     Urinary  bladder  normal. 


32  GOVERNMENT    HOSPITAL    FOR    THE    INSANE. 

Liver:  Weight  45£  ounces  (1,207.01  grams).  Tissue  showed  slight 
passive  congestion  and  some  bile-staining;  edges  of  left  lobe  somewhat 
thin  and  fibrous.  Gall-bladder  contained  2  ounces  of  bile  and  one 
calculus  of  medium  size. 

The  other  organs  were  normal  to  the  naked  eye. 

MICROSCOPICAL    EXAMINATION. 

The  tumor  consists  of  slender  spindle  cells  with  oval  or  elongated 
nuclei  and  arranged  in  whorls  or  cell  nests  and  bands  running  in  every 
direction.  These  bands  when  cut  transversely  present  the  appearance 
of  small  groups  of  round  cells  with  round  nuclei.  The  whorls  or  cell- 
nests  are  round  or  oval.  They  are  of  all  sizes,  and  occasionally  two  or 
more  concentrically  arranged  cell-masses  are  surrounded  by  a  common 
band  of  spindle  cells.  Bands  of  delicate  connective  tissue  and  spindle 
cells  run  through  the  growth,  separating  the  tissue  into  groups  or 
masses  in  some  fields. 

The  blood  vessels  were  not  numerous;  they  have  imperfectly  devel- 
oped walls,  and  are  found  in  the  dense,  spindle-celled  tissue,  sometimes 
surrounded  by  several  layers  of  spindle  cells  and  sometimes  running 
parallel  with  the  spindle  cells  in  the  dense  bands.  Vessels  are  also 
found  in  the  loose  connective  tissue  between  the  cell  groups.  Portions 
of  the  included  falx  contain  the  preexisting  vessels. 

A  peculiar  feature  of  the  tumor  is  the  presence  of  great  numbers 
of  h}Taline  masses  of  all  sizes,  from  bodies  visible  to  the  naked  eye 
down  to  the  size  of  an  epithelial  cell.  The  spheres  of  hyaline  material 
are  usually  found  in  the  centers  of  the  dense  cell- whorls,  and  are  sur- 
rounded by  several  la}^ers  of  unchanged  spindle  cells.  The  fact  that 
cylinders  of  hyaline  material  are  found  in  the  centers  of  some  of  the 
dense  bands  shows  that  the  h}Taline  masses  must  be  the  product  of  some 
kind  of  cell  degeneration.  The  presence  of  cell-whorls  in  the  transi- 
tion stages  of  the  hyaline  change  is  additional  proof  of  the  nature  of 
these  bodies.  Transverse  and  oblique  sections  of  the  hyaline  cylinders 
resemble  the  spherules  in  every  respect,  but  the  direction  of  the  sur- 
rounding cells  enables  us  to  distinguish  between  them.  Occasionally 
a  vessel  is  found  with  some  hyaline  degeneration  of  its  walls.  The 
diagnosis  in  this  case  is  spindle-celled  sarcoma  of  dura  mater. 

The  examination  of  the  brain  shows  advanced  degeneration  of  the 
nerve-cells  of  the  cortex.  The  vessels  are  curved  and  tortuous,  and 
pigment  is  scattered  along  their  walls.  •  Other  parts  of  the  brain  show 
the  same  general  condition. 

The  microscope  confirmed  the  diagnosis  of  the  condition  of  the  other 
organs. 

CASE  1146. 

SPINDLE-CELLED    ENDOTHELIAL    SAKCOMA    OF    THE    DURA     MATER    AND 
SOFT   CARCINOMA    OF   THE    STOMACH. 

J.  D. ;  aged  59;  white;  single;  shoemaker;  late  soldier;  nativhVv,  New 
York;  mental  disease,  chronic  mania;  duration,  twelve  }7ears.  No  his- 
tory of  the  patient  previous  to  his  admission  to  the  hospital  could  be 
obtained.  It  was  improbable  that  occupation  or  habits  of  life  could 
have  had  any  influence  on  the  development  of  the  tumors,  though  the 
condition  of  some  of  the  organs  may  have  been  due  to  the  abuse  of 


GOVERNMENT    HOSPITAL    EOR   THE    INSANE.  33 

stimulants.  The  dural  tumor  was  probably  of  long  standing;  the  car- 
cinoma was  of*uncertain  duration.  The  tumor  of  the  dura  gave  rise  to 
no  characteristic  symptoms,  and  the  presence  of  the  cancer  was  only 
indicated  by  some  gastric  pain  and  occasional  vomiting-  after  eating. 
It  is  almost  certain  that  the  vomiting  was  duo  to  the  gastric  tumor 
rather  than  that  of  the  dura,  as  the  latter  was  of  small  size  and  all 
other  symptoms  of  intracranial  growth  were  absent.  The  mental  dis- 
ease beginning  with  maniacal  excitement  gradually  gave  way  to  ter- 
minal dementia  of  a  moderate  degree,  and  for  some  time  previous  to 
his  death  the  patient  was  employed  at  light  work  about  the  kitchen. 
He  gradually  failed,  and  died  from  exhaustion  and  inanition  due  to  the 
condition  of  the  stomach. 

Autopsy  eighteen  hours  after  death:  Body  small,  greatly  emaciated, 
rigor  mortis  disappearing.  Cranium:  Antero-posterior  diameter  of 
skull,  7f  inches;  transverse,  5&,  inches.  Shape,  asymmetrical,  the  left 
side  being  the  larger;  sutures  partly  obliterated;  bone  of  normal  thick- 
ness. The  outer  surface  of  the  skull  bone  was  roughened  and  irregu- 
lar in  patches  and  showed  a  number  of  irregular  depressions  to  which 
the  pericranium  adhered.  In  the  occipital  region  some  of  these 
depressed  areas  yet  remained  soft  and  could  be  penetrated  with  the 
knife.  The  dura  mater  was  adherent  to  the  bone,  but  perhaps  not 
abnormally  so  for  a  man  of  his  age. 

On  the  inner  surface  of  the  dura  over  the  anterior  part  of  the  right 
third  frontal  convolution  was  a  small  globular  tumor  mass  about  three- 
fourths  of  an  inch  in  diameter,  firmly  adherent  to  the  dura  mater  and 
also  attached  to  the  pia,  so  that  it  could  not  be  removed  without  tear- 
ing the  latter.  The  tumor  had  made  a  slight  depression  in  the  con- 
volution, but  there  was  no  loss  of  substance.  The  other  portions  of 
the  dura  seemed  a  little  thickened,  and  a  small  nodule  similar  to  the 
tumor  described  above  was  found  on  the  inner  surface  over  the  left 
occipital  region.  This  nodule  had  caused  no  depression  in  the  brain. 
Section  showed  the  tumor  to  be  fibrous  in  structure,  grayish-red  color, 
firmly  united  with  the  dura  and  pia,  but  evidently  derived  from  the 
former.  The  tissue  was  moderately  firm,  and  slight  grittiness  was 
noticed  on  section. 

Brain:  Weight  of  each  hemisphere,  21  ounces  (595.35  grams);  cere- 
bellum, pons,  and  medulla,  5f  ounces  (163  grams).  The  pia  mater 
showed  a  moderate  degree  of  vascular  engorgement  and  some  oedema, 
but  no  opacity  or  other  alteration  except  as  mentioned  above.  Arteries 
at  the  base  not  diseased.  The  brain  tissue  was  very  soft  and  cedem- 
atous  and  section  showed  enlargement  of  the  perivascular  spaces  every- 
where. The  ventricles  were  moderately  enlarged;  epend}Tma  smooth. 
Cerebellum,  pons,  and  medulla  were  oedematous  and  soft;  a  small 
congested  area  was  found  in  the  right  side  of  the  pons,  exposed  by 
middle  transverse  section. 

Thorax. — Limited  chronic  pleuritic  adhesions  on  both  sides,  and  a 
small  quantity  of  fluid  in  each  plural  cavity. 

Lungs:  Weight  of  each,  20i  ounces  (581  grams).  Posterior  por- 
tions of  both  lungs  showed  oedema  and  some  hypostatic  exudate  in 
patches.     Over  the  lower  lobe  of  the  left  was  a  thin  deposit  of  lymph. 

Heart:  Weight,  6f  ounces  (191  grams).  The  superficial  arteries 
were  very  tortuous  and  calcified;  opaque  patch  over  wall  of  right  ven- 
tricle; valves  of  right  side  normal;  aortic  valves  normal;  mitral  valve 

21648—03 3 


34  GOVERNMENT    HOSPITAL    FOR    THE    INSANE. 

a  little  thickened  at  its  edges.  Heart  muscle  brownish  and  super- 
ficial adipose  tissue  atrophied  and  (.edematous.  Aorta* atheromatous 
throughout. 

Abdomen. — The  abdominal  cavity  contained  112  ounces  of  straw- 
colored  fluid.  The  appendix  vermiform  is  was  turned  upward  and 
backward  and  was  adherent  to  the  peritoneum. 

Spleen:  Weight,  7f  ounces  (219  grams):  capsule  wrinkled  and  carti- 
laginoid  in  patches:  pulp,  slate-colored,  rather  pale,  and  fibrous.  Small 
supernumerary  spleen  near  the  hilus. 

Kidneys:  Weight  of  left,  4£  ounces  (127.5  grams);  right,  4  ounces 
(113.1  grams).  The  organs  were  somewhat  indurated;  capsules  adher- 
ent: surfaces  slightly  granular;  cortex  rather  thin;  apices  of  pyramids 
whitened  by  urate  deposits.     Urinary  bladder,  normal. 

Liver:  Weight,  47^  ounces  (1 34<>.  62  grams).  The  surface  was  slightly 
granular;  edges  somewhat  rounded;  upper  surface  of  right  lobe  cov- 
ered by  a  thin  layer  of  apparently  organized  lymph,  but  it  was  not 
adherent  to  the  diaphragm.  The  capsule  showed  some  radiating  scars 
over  the  superior  surface;  there  was  some  general  thickening  of  the 
capsule  in  the  region  of  the  gall  bladder,  and  a  large  depressed  scar 
was  found  in  the  under  surface  of  the  right  lobe.  The  tissue  was 
tough  and  leathery,  and  the  cut  surface  was  almost  homogeneous  in 
appearance,  without  any  trace  of  lobulation,  or  bands  of  connective 
tissue,  such  as  are  usualh7  seen  in  common  cirrhosis  of  the  liver/'  The 
gall-bladder  was  normal. 

Stomach:  At  the  pyloric  end  of  the  stomach  was  a  large  fungoid 
growth,  which  bordered  upon  the  pyloric  orifice,  but  did  not  obstruct 
it  to  an  appreciable  degree.  The  growth  was  nearly  two  inches  across 
in  its  greatest  diameter  and  about  three-fourths  of  an  inch  in  average 
thickness.  The  surface  was  ulcerated  and  hemorrhagic;  tissue  was 
soft  and  juicy  on  section.  The  general  surface  of  the  stomach  showed 
a  granular  condition  and  some  opacity  of  the  mucous  membrane. 

Intestines:  ISo  lesions  were  found  in  the  intestines;  mesenteric  glands 
slightly  enlarged  but  not  cancerous. 

Other  abdominal  organs  were  normal.  No  trace  of  secondary  tumor 
deposits  was  found. 

MICROSCOPICAL   EXAMINATION. 

Dural  tumor:  On  superficial  examination  the  tumor  much  resembled 
a  hard  fibroma,  but  on  careful  study  it  was  found  that  the  fibrous- 
looking  tissue  could  be  resolved  into  spindle  cells  with  oval  and 
elongated  nuclei  arranged  in  wavy  bands,  whorls,  and  concentrically 
arranged  cell  spherules,  such  as  are  commonly  found  in  tumors  of  this 
class.  The  cell  nuclei  were  very  hard  to  stain  and  the  cell  bodies 
could  not  be  distinguished  when  in  masses.  There  was  undoubted^  a 
considerable  development  of  actual  fibrous  tissue  and  some  hyaline 
change,  which  gave  the  tissue  the  peculiar  appearance  of  a  dense 
fibroma.  The  closely  packed  cell  masses  of  various  sizes  were  very 
numerous  in  some  parts  of  the  sections.  In  man3T  of  these  the  cellular 
structure  could  hardly  be  determined,  owing  to  fibrous  and  hyaline 
change,  and  in  some  the  degeneration  had  reached  the  stage  of  forma- 
tion of  the  concentric-all}7  striated  hyaline  and  calcareous  spherules, 
such  as  shown  in  fig.  12.      Besides  these  spherules,  large  irregular 

«  The  condition  of  the  bone  of  the  skull  and  the  peculiar  variety  of  cirrhosis  of 
the  liver  suggested  syphilis,  but  as  there  was  no  proof  of  the  existence  of  specific 
disease  it  was  not  mentioned  in  the  history  of  the  case. 


GOVERNMENT    HOSPITAL    FOR   THE    INSANE.  35 

aieas  of  the  same  degenerative  product  were  found  in  the  large  tissue 
masses  where  the  cell  structure  was  unusually  dense.  Blood  vessels 
were  not  numerous,  and  those  in  the  sarcomatous  tissue  had  imperfect 
walls,  though  some  fully  developed  vessels  were  found  in  masses  of 
connective  tissue,  apparently  derived  from  the  dura.  Hyaline  change 
in  the  vessels  was  not  marked. 

The  histogenesis  of  such  tumors  is  certainly  very  obscure,  but  the}' 
are  generally  supposed  to  be  derived  from  the  endothelium  of  the 
brain  membranes,  and  are  therefore  called  endotheliomata  by  many 
pathologists.  On  account  of  the  shape  of  the  predominating  type  of 
cells,  which  are  spindle-shaped  and  not  endotheloid,  I  have  named 
this  and  other  like  tumors  spindle-celled  endothelial  sarcoma.  The 
.  presence  of  the  hyaline  and  calcified  spherules  being  only  accidental 
should  not  warrant  the  use  of  such  terms  as  psammoma,  acervuloma, 
etc.,  especially  as  the  identity  of  these  bodies  with  "brain  sand"  is 
not  established. 

Cancer  of  stomach:  The  cancer  of  the  stomach  was  of  the  soft 
varietjr,  and  probably  originated  in  the  fundus  cells  of  the  pyloric 
glands.  The  cells  were  rather  small,  with  prominent  nuclei,  and, 
where  not  influenced  by  mutual  pressure,  round.  The  growth  was 
mainly  in  the  mucosa,  and  no  trace  of  gland-like  tissue  remained, 
except  a  tendency  of  some  of  the  peripheral  cells  to  arrange  them- 
selves in  a  single  la}-er  along  the  walls  of  the  alveoli  and  to  assume 
columnar  shape  by  mutual  pressure.  The  growth  had  penetrated  very 
little  into  the  muscular  coats  of  the  organ,  but  a  few  cancer  cell-nests 
were  found  in  the  connective  tissue  trabecule  separating  the  muscular 
bundles  of  the  circular  layer.  These  cancerous  masses  were  always 
surrounded  by  dense,  small  cell  infiltration.  The  growth  had  not 
invaded  any  other  organ  or  tissue. 

Brain:  The  brain  tissue  was  unfit  for  the  more  minute  study  of 
structure,  on  account  of  decomposition  at  the  time  of  the  autopsy. 
In  ordinary  sections  the  cells  showed  granular  pigmentary  degenera- 
tion; the  pericellular  spaces  were  large*;  the  blood  vessels  had  large 
perivascular  spaces,  but  showed  no  disease  of  their  walls.  The  cells 
of  the  spinal  cord  were  granular  and  pigmented. 

The  lungs  showed  some  exudation  in  the  alveoli  of  the  dependent 
portions.  The  kidneys  showed  a  moderate  increase  of  connective  tis- 
sue in  the  vicinit}^  of  the  glomeruli  and  between  the  tubules.  The 
cells  of  the  convoluted  tubules  were  crumbled,  and  granular  matter 
filled  the  lumen  of  the  tubules. 

The  spleen  showed  enlargement  of  the  venous  sinuses  and  swelling 
and  proliferation  of  the  endothelium.  The  connective  tissue  was 
increased;  the  capsule  much  thickened,  especially  in  the  cartilaginoid 
patches. 

Liver:  The  microscopical  appearances  of  the  liver  were  veiy  unusual. 
There  was  a  moderate  increase  of  the  connective  tissue  between  the 
lobules  and  in  the  portal  canals.  This  tissue  was  richly  nucleated  in 
patches,  and  at  the  borders  of  these  areas  the  tissue  extended  for  some 
distance  between  the  cell  columns  and  the  individual  cells.  There  was 
no  unusual  proliferation  of  the  bile  ducts  in  the  new  connective  tissue. 
In  some  places  patches  of  new  connective  tissue  were  found  among  the 
cells,  which  were  widely  separated,  misshapen,  and  atrophied.  Occa- 
sionally isolated  groups  of  leucocytes  were  found  among  the  cells,  with- 
out any  relation  to  the  connective-tissue  areas.  They  were  supposed  to 
be  centers  of  new  growth. 


36  GOVERNMENT    HOSPITAL    FOR   THE    INSANE. 

In  general,  the  liver  colls  were  atrophied  and  the  cell  columns  were 
widely  separated  by  dilated  capillaries.  In  some  places  this  dilatation 
was  excessive  and  had  almost  reached  the  angiomatous  stage,  the  cells 
having  completely  disappeared.  The  diagnosis  of  the  condition  of  the 
liver  was  difficult,  but  taken  in  connection  with  the  naked-eye  appear- 
ances, specific  cirrhosis  would  certainly  be  suggested. 

The  mesenteric  glands  seemed  to  be  merely  hyperplastic,  as  no  can- 
cerous deposits  were  found  in  them.  Other  abdominal  organs  were 
not  examined  with  the  microscope. 

CASE   1516. 

SPINDLE-CELLED   ENDOTHELIAL    SARCOMA    OF    THE    DURA    MATER   PENE- 

TRATING  THE   BRAIN. 

J.  M. ;  aged  78;  widower;  late  soldier;  nativity,  France.  Mental 
disease,  senile  dementia;  duration,  unknown. 

The  symptoms  in  this  case  had  probably  no  reference  to  the  intra- 
cranial growth.  It  was  small,  pressed  slightly  upon  the  brain,  pro- 
duced no  appreciable  intracranial  tension,  and  encroached  npon  no 
important  structure.  The  patient  was  feeble  and  bedridden,  but  there 
was  no  paralysis.  The  mental  symptoms  were  dementia  with  con- 
siderable maniacal  excitement,  and  much  of  the  time  he  was  apparently 
unconscious  of  hi*  surroundings.  Death  seemed  to  be  due  to  exhaus- 
tion from  manical  excitement  and  general  senile  enfeeblement. 

Autopsy  seven  hours  after  death.  Body  of  average  size;  well 
developed;  dependent  parts  of  body  livid.  Direct  inguinal  hernia  of 
right  side. 

Cranium. — Skull  thin  and  porous;  shape,  symmetrical;  anteropos- 
terior diameter,  7&  inches;  transverse,  5f  inches.  Dura  mater  was 
adherent  to  the  bone,  and  on  the  basal  portion  on  the  right  side  was  a 
small  tumor  which  pressed  inward  upon  the  brain  at  the  entrance  of  the 
fissure  of  Sylvius.  The  growth  had  made  but  a  slight  depression  in 
the  brain  and  there  was  no  appreciable  increase  of  intracranial  pres- 
sure. The  growth  had  the  usual  appearance  of  dural  tumors  of  this 
class;  it  was  moderately  hard,  and  firmly  adherent  to  the  dura.  No 
adhesions  to  the  brain' were  present  and  the  cortex  was  apparently 
uninjured. 

Brain:  Weight,  1,200  grams.  The  convolutions  were  generally 
shrunken;  arteries  at  the  base  atheromatous;  ventricles  enlarged;  brain 
tissue  soft  and  oedematous.  No  gross  lesions  were  found  in  any  part  of 
brain.  Left  optic  nerve  atrophied,  corresponding  with  loss  of  sight 
of  the  eye. 

Thorax. — Lungs  emphysematous,  pigmented,  and  contained  a  few 
fibrous  nodules.  Weight  of  the  right  lung,  400  grams;  left,  300 
grams. 

Heart:  Weight,  350  grams.  The  valves  of  right  side  were  normal, 
except  some  increase  of  the  size  of  the  tricuspid  orifice.  The  mitral 
was  a  little  thickened  at  the  margins;  orifice  normal;  aortic  valves  cal- 
careous at  their  attached  margins  and  somewhat  pouched.  Aorta  and 
coronary  arteries  atheromatous. 

Abdomen. — Spleen  soft  and  dark;  capsule  thickened  and  wrinkled; 
weight,  100  grams. 

Kidneys:  Weight  of  right,  120  grams;  left,  160  grams.  The  capsules 
were  adherent;  surfaces  granular  and  cystic;  cortex  thin;  pyramids 


GOVERNMENT    HOSPITAL    FOR    THE    INSANE.  37 

atrophied.  Bladder  hypcrtrophied  and  sacculated  from  obstruction 
of  the  urethra  by  enlargement  of  the  prostate  gland. 

Liver:  Weight,  950  grams.  Organ  rather  small  and  somewhat 
congested. 

Other  organs  showed  nothing  of  importance. 

MICROSCOPIC    EXAMINATION. 

The  tumor  proved  to  be  a  spindle-celled  endothelial  sarcoma.  The 
structure  consisted  of  spindle  cells  with  oval  and  elongated  nuclei  and 
clear  or  faintly  granular  cell  bodies,  closely  applied  to  each  other,  with 
no  perceptible  intercellular  substance  in  the  denser  masses.  In  some 
parts  of  the  growth  the  cells  were  more  loosely  arranged,  and  faint 
indications  of  fibrillated  intercellular  tissue  could  be  seen.  The  cells 
were  arranged  in  beautifully  curved  bands,  running  in  every  direction 
and  in  concentrically  arranged  cell  spherules,  which  had  frequently 
been  changed  to  pearly  hyaline  bodies,  so  characteristic  of  this  form 
of  growth.  Hyaline  spherules  of  medium  size  were  veiy  common, 
and  occasionally  whole  fields  were  found  consisting  of  closely  set  cell 
spherules  undergoing  hyaline  change,  as  shown  in  fig.  21.  In  addi- 
tion to  these  hyaline  cell  nests,  there  were  in  some  parts  of  the  tumor 
numerous  hyaline  rods  lying  among  the  cells  and  often  intermingled 
with  each  other  and  with  the  cells  in  an  indescribable  wa}\  As  a  rule, 
these  rods  seemed  to  be  found  in  bundles  of  cells  running  in  the  same 
direction,  and  were  evidently  due  to  Iryaline  transformation  of  cells, 
shown  by  the  persistence  of  slender  nuclei  in  the  midst  of  the  hyaline 
material.  When  cut  transversely,,  these  hyaline  rods  were  seen  to  be 
cylindrical  or  rounded,  and  occasional^  showed  a  central  portion  or 
core  which  stained  deeply  in  hematoxylin,  similar  to  the  central  por- 
tions of  some  of  the  h}raline  spherules. 

Blood  vessels  were  not  numerous,  and  were  frequently  represented 
b}^  mere  channels  among  the  cells.  Some  showed  a  small  quantitj7  of 
fibrous  tissue  forming  an  adventitia,  but  connective  tissue  was  scant}7, 
and  there  was  no  appreciable  division  of  the  cell  groups  hy  vascular 
connective  tissue,  as  in  many  tumors  of  this  class. 

Adhesions  to  the  dura  mater  were  found  to  be  intimate,  and  the 
origin  from  this  membrane  was  indicated  b}7  a  gradual  transition  from 
the  fibrous  tissue  of  the  dura  to  the  spindle-cell  structure  of  the  tumor. 

The  brain  was  not  examined  with  the  microscope,  as  its  condition 
had  probably  no  relation  to  the  tumor. 

The  kidneys  showed  advanced  interstitial  nephritis,  and  a  small 
papuliferous  cyst  adenoma  was  found  in  one  of  the  tissue  blocks 
sectioned.  Others  may  have  existed,  but  were  invisible  to  the  naked 
eye,  as  was  this  one. 

Other  organs  were  not  examined  with  the  microscope. 

CASE   965. 
SPINDLE-CELLED    SARCOMA    OF   DURA   MATER. 

C.  S. ;  aged  77  years;  married;  farmer;  late  soldier;  nativity,  Ger- 
rnanj7.  Mental  disease,  senile  dementia;  duration  unknown.  The  his- 
tory shows  that  the  mental  power  failed  gradually;  hearing  and  vision 
were  defective;  there  was  general  feebleness,  but  no  distinct  paralysis. 


38  GOVERNMENT    HOSPITAL    FOR    THE    INSANE. 

There  was  a  history  of  rheumatism,  and  he  was  known  to  have  valvu- 
lar disease  of  the  heart.  There  were  no  characteristic  symptoms  of 
brain  tumor,  and  those  given  above  were  attributed  to  his  advanced 
age.     Failure  of  the  diseased  heart  was  the  immediate  cause  of  death. 

Autopsy  fourteen  hours  after  death.  Body  large  and  (edematous; 
posterior  portions  of  body,  face,  and  neck  diseolored. 

L'i'<inin in.—  Antero-posterior  diameter  of  skull,  7  inches;  transverse, 
6  inches.  Bone  a  little  thicker  than  the  average;  sutures  indistinct  in 
both  tables;  posterior  border  of  the  sella  turcica  extended  about  one- 
eighth  of  an  inch  above  its  usual  position.  Dura  mater  adherent  to 
the  bone,  but  otherwise  normal;  no  perceptible  increase  of  intracranial 
tension;  cerebro-spinal  fluid  increased. 

Brain:  Weight,  40  ounces  (1,184  grams).  On  removal  of  the  brain 
a  tumor  was  found  in  the  base,  situated  in  the  left  temporal  lobe 
adjoining  the  junction  of  the  pons  and  crus,  but  not  pressing  upon 
either.  The  tumor  had  penetrated  the  brain  through  the  middle  of 
the  gyrus  occipitotemporal  is  medialis,  pressing  the  brain  substance 
aside  and  causing  some  absorption  of  the  tissue  in  its  advance.  The 
growth  was  about  1^  inches  in  its  longest  diameter  and  had  penetrated 
nearly  an  inch  into  the  brain.  The  portion  which  had  invaded  the 
brain  was  rounded,  but  the  exposed  surface  was  Hat  and  level  with  the 
basal  surface  of  the  brain,  and  had  rested  on  the  tentorium  at  its  ante- 
rior angle.  The  surface  on  which  the  tumor  rested  was  slightly 
roughened,  but  the  libers  of  the  membrane  could  be  seen  running 
beneath  without  interruption,  and  it  was  difficult  to  believe  that  the 
growth  originated  from  the  membrane,  as  such  tumors  frequently  do. 
Section  through  the  middle  of  the  growth  showed  the  tissue  to  be  dry, 
granular  in  appearance,  reddish-gra}^  in  color,  and  minute  gritty  par- 
ticles could  be  felt  on  the  cut  surface.  The  growth  was  sharply  defined 
by  an  imperfect  capsule  and  there  was  no  infiltration  of  the  brain 
tissue. 

The  convolutions  were  generally  somewhat  atrophied  and  separated 
by  the  oedematous  pia  mater;  there  were  no  signs  of  pressure  except 
locally  around  the  tumor.  At  the  base  of  the  right  occipital  lobe  was 
a  small  cortical  softening.  The  arteries  at  the  base  were  atheromatous 
in  patches;  the  left  vertebral  was  large  and  joined  the  basilar  without 
change  of  caliber;  the  right  wTas  very  small.  Section  of  the  brain 
showed  oedema  and  pallor  of  the  brain  tissue,  but  no  other  gross  lesions. 
The  cerebellum,  pons,  and  medulla  were  in  the  same  general  condition 
as  the  cerebrum,  and  the  cervical  portion  of  the  spinal  cord  removed 
with  the  brain  seemed  normal. 

Thorcwo. — Limited  pleuritic  adhesions  on  both  sides.  Lungs:  Weight 
of  left,  25  ounces  (717.75  grams);  right,  40f  ounces  (1,155.26  grams). 
Over  the  anterior  portion  of  the  pleura  of  both  lungs  were  small, 
thickened  fibroid  nodules;  pulmonary  tissue  oedematous;  posterior 
portions  engorged. 

Heart:  Weight,  20±  ounces  (583.08  grams).  Pericardial  fluid 
increased;  both  layers  of  the  pericardium  were  covered  by  opaque 
thickened  patches,  in  some  of  which  were  flakes  of  calcareous  deposit. 
The  pulmonary  valves  were  large  and  slightly  thickened;  tricuspid 
valve  admitted  four  fingers  and  was  thickened  at  its  margins.  Aortic 
valves  were  thickened,  rigid  with  calcareous  deposits,  and  roughened 
by  vegetations  along  line  of  contact.  The  mitral  valve  was  thick  and 
contracted  at  its  edges;  orifice  admitted  three  fingers.     The  chorda? 


GOVERNMENT    HOSPITAL    FOR   THE    INSANE.  39 

tendinse  were  thicker  than  normal;  summits  of  muscular  papilla;  fibrous; 
endocardium  of  left  ventricle  opaque.  The  heart  walls  were  byper- 
trophied  and  the  cavities  all  dilated.  Section  of  the  heart  muscle 
revealed  a  number  of  small  patches  of  interstitial  myocarditis,  espe- 
cially in  the  wall  of  the  left  ventricle  and  the  septum.  The  arch  of  the 
aorta  was  dilated;  the  intima  showed  slight  fatty  degeneration 

Abdomen. — The  spleen  weighed  K)^  ounces  (291.28  grams);  capsule 
tense  and  a  little  thickened;  pulp  (edematous  and  soft. 

Kidneys:  Weight  of  left,  G  ounces  (170.10  grams);  right,  5i  ounces 
(155.92  grams).  Capsules  not  adherent;  surfaces  faintly  granular  and 
showed  a  few  depressions  and  small  cysts.  Cortex  normal  in  thickness; 
pyramids  rather  pale.     Urinary  bladder  normal. 

Liver:  Weight,  59£  ounces  (1,693.91  grams).  Surface  faintly  gran- 
ular; capsule  clouded  in  patches,  and  over  the  left  lobe  was  a  large 
fibrous  patch,  where  it  came  in  contact  with  the  diaphragm  beneath 
the  pericardium.  The  tissue  showed  some  passive  congestion.  Gall 
bladder  normal. 

The  stomach  showed  a  marked  constriction  about  its  middle,  and 
the  walls  were  thickened,  thrown  into  large  folds,  and  covered  by  tough 
mucus.  Some  small  erosions  and  areas  of  congested  vessels  were 
revealed  by  the  removal  of  the  coating  of  mucus. 

There  were  some  old  peritoneal  adhesions  in  the  vicinity  of  the  ascend- 
ing colon  and  gall-bladder.     Other  abdominal  organs  were  normal. 

MICROSCOPICAL   EXAMINATION. 

Tumor:  The  growth  was  extremely  difficult  to  cut  on  account  of  its 
friability,  and  the  edge  of  the  knife  was  broken  by  the  calcareous  par- 
ticles. The  tissue  consisted  of  irregular,  wavy  spindle  cells  arranged 
in  concentric  masses,  and  bands  running  in  every  direction,  and  a  few 
round  cells  sometimes  collected  into  small  areas.  The  most  striking 
feature  of  the  structure  was  the  presence  of  vast  numbers  of  concen- 
trically striated  hyaline  spherules  of  all  sizes,  with  which  the  tissue 
was  literally  crowded.  Some  were  as  small  as  an  epithelial  cell,  some 
were  large  enough  to  be  distinguished  with  the  naked  e}Te.  Some  of 
the  largest  were  composed  of  two  or  more  globes  fused  together  and 
surrounded  by  a  common  capsule  consisting  of  the  same  hyaline  lami- 
nated material.  Fields  were  found  in  which  the  cells  were  nearly  all 
crowded  out  by  these  hyaline  bodies,  and  those  yet  remaining  were 
frequently  compressed  between  the  closely  set  spherules.  Many  of  the 
hyaline  bodies  were  more  or  less  calcified  in  their  centers;  such  were 
apt  to  be  displaced  by  the  section  knife,  and  often  appeared  partly 
turned  over.  In  optical  section  the  hyaline  bodies  appeared  as  disks, 
but  when  turned  over  and  viewed  in  profile  they  appeared  as  seg- 
ments of  spherules  made  wherever  the  section  knife  happened  to  pass 
through  them.  In  the  majority  of  the  hvaline  globes  of  all  sizes  flat- 
tened elongated  nuclei  were  seen  between  the  lamina?;  in  some  these 
nuclei  were  very  numerous,  suggesting  strongly  the  appearance  of  the 
denser  cell  whorls  found  in  such  tumors. 

Some  of  the  hyaline  bodies  stained  well  in  the  nuclear  stains,  some 
stained  faintly,  and  others  not  at  all.  Where  calcified  they  were 
opaque  and  coarsely  granular;  when  not  they  were  clear  and  transpar- 
ent. Their  true  chemical  nature  is  not  definitely  determined,  and  the 
term  hyaline,  as  applied  to  them,  is  used  in  its  descriptive  sense  only. 


40  GOVERNMENT    HOSPITAL    FOR    THE    INSANE. 

That  they  represent  some  kind  of  degenerative  change  in  the  dense 
cell  masses  seems  quite  reasonable  to  the  writer. 

Very  few  blood  vessels  were  found;  those  discovered  seemed  to  run 

among  the  cells  without  definite  direction  relative  to  the  cell  .structure. 
Very  little  connective  tissue  was  found  except  at  the  periphery  of  the 
tumor  and  in  the  vicinity  of  some  of  the  Largest  vessels. 

The  growth  was  regarded  as  essentially  a  spindle-celled  sarcoma  on 
account  of  the  predominant  cell  elements,  but  it  is  probable  that  such 
tumors  have  been  described  as  psammoma. 

The  brain  tissue  showed  nothing-  of  importance  except  the  effects  of 
oedema  and  some  degeneration  of  the  nerve  cells. 

The  other  organs  were  not  examined  with  the  microscope,  as  their 
condition  seemed  sufficiently  clear  to  the  unaided  eye. 

CASE  1503. 

SPINDLE-CELLED  ENDOTHELIAL   SARCOMA  OF  DURA  MATER   PENETRATING 

THE    BRAIN. 

A.  W.,  aged  6G\  married;  laborer;  colored;  nativity,  South  Caro- 
lina. Mental  disease,  chronic  epileptic  dementia;  duration,  ten  years. 
In  this  case  there  were  no  symptoms  indicating  tumor  of  brain  except 
the  dementia  and  the  convulsions:  the  latter  being  distinctly  epileptic 
led  to  the  diagnosis  of  epilepsy,  and  the  accompanying  dementia  was 
attributed  to  this  disease.  Headache  was  not  complained  of;  vomiting- 
was  not  observed,  and  though  ophthalmoscopic  examination  was  not 
made,  there  was  no  special  affection  of  sight.  The  situation  of  the 
tumor  invasion  being  in  advance  of  all  motor  areas,  paralyses  were  not 
to  be  expected.  The  exact  relation  of  the  the  growth  to  the  epilepsy 
and  dementia  is,  of  course,  hard  to  determine,  but  it  is  reasonable  to 
conclude  that  the  penetration  of  the  brain  by  the  tumor  might  act  as  a 
traumatic  cause  of  the  convulsive  seizures.  The  length  of  time  the 
disease  existed  would  agree  well  with  the  supposed  slow  growth  of 
tumors  of  this  class. 

The  immediate  cause  of  death  was  cystitis  and  pyelo-nephritis. 
brought  about  by  moderate  but  ball-valve-like  enlargement  of  the 
middle  lobe  of  the  prostate  gland. 

Autopsy  six  hours  after  death.  Muscular  system  well  developed; 
body  fairly  well  nourished;  scar  on  left  forearm. 

Uranium. — Antero-posterior  diameter  of  the  skull,  7i  inches;  trans- 
verse diameter,  5i  inches;  skull  of  the  usual  thickness;  shape  symmet- 
rical; sutures  indistinct;  dura  mater  adherent  to  the  bone,  but  not 
abnormally  so  for  the  age  of  the  patient. 

Brain:  Weight,  1,180  grams.  There  was  no  sign  of  intracranial 
tension,  and  the  convolutions  were  moderately  separated  by  oedema. 
A  tumor  of  dural  origin  was  found  embedded  in  the  brain  at  the  lower 
and  anterior  part  of  the  right  frontal  lobe.  The  growth  had  invaded 
the  anterior  portion  of  the  third  frontal  convolution  and  the  adjoining- 
portion  of  the  orbital  convolutions.  The  tumor  was  about  li  inches 
in  its  greatest  diameter,  and  extended  into  the  brain  about  an  inch. 
It  was  firmly  adherent  to  the  dura  mater  and  had  penetrated  the  brain 
mechanically,  carrying  the  pia  mater  and  cortex  in  front  of  it,  except 
at  one  place,  where  softening  of  the  cortex  had  taken  place.  The 
growth  was  easily  enucleated  from  the  brain  and  was  without  capsule 
of  any  sort,  as  was  subsequently  proven  by  the  aid  of  the  microscope. 


GOVEENMENT    HOSPITAL    FOR    THE    INSANE.  41 

The  brain  tissue  in  the  vicinity  was  not  appreciably  softened,  as  is 
sometimes  the  case. 

The  growth  was  moderately  firm  in  consistence,  pale  reddish  gray 
in  color,  and  on  section  it  seemed  gritty  and  friable.  In  tin;  central 
portion  the  tissue  was  of  a  yellowish -white  color  and  evidently  calci- 
ned; the  outer  portion  was  grayish  red  in  color  and  softer,  apparently 
of  more  recent  growth. 

The  brain  substance  was  cedematous  and  somewhat  soft.  The  arteries 
at  the  base  were  atheromatous,  but  there  were  no  gross  lesions  in  any 
part  of  the  brain. 

Thorax. — Left  lung  could  not  be  removTed  on  account  of  firm  adhe- 
sions; right  lung  weighed  680  grams;  the  bronchi  contained  muco- 
purulent secretion,  and  the  posterior  portions  were  solidified  by 
hypostatic  pneumonia. 

Heart:  Weight,  380  grams.  Valves  of  right  side  not  diseased, 
except  relative  incompetency  of  the  tricuspid  valve.  Aortic  valves 
were  somewhat  thickened  and  calcareous;  mitral  valve  slightly  thick- 
ened at  its  free  margins.  The  auricles  were  dilated;  the  left  ventricle 
hypertrophied;  superficial  arteries  tortuous  and  rigid;  aorta  corrugated 
and  dilated  at  the  arch,  and  at  the  lower  part  atheromatous  and  cal- 
cified in  patches. 

Abdomen. — The  spleen  weighed  220  grams,  was  enlarged,  moderately 
firm,  and  congested. 

Kidnej^s:  Weight  of  each,  180  grams.  The  left  was  swollen, 
cedematous,  and  the  cortex  was  streaked  with  blood  and  contained 
some  small  pus  deposits.  The  right  was  in  the  same  general  condition, 
but  no  pus_  had  yet  formed.  The  pelves  and  ureters  showed  acute 
inflammation  and  contained  muco-pus. 

The  bladder  showed  intense  inflammation  and  the  walls  were  ulcer- 
ated and  in  part  covered  by  a  dirty  gray  and  hemorrhagic  false  mem- 
brane. The  middle  portion  of  the  prostate  gland  was  greatly  enlarged 
and  had  acted  as  a  valve-like  obstruction  to  the  urethral  orifice.  This 
prominent  portion  of  the  gland  had  been  injured  by  the  efforts  at 
catheterization  and  was  the  seat  of  some  hemorrhagic  extravasation 
within. 

The  liver  weighed  1,600  grams.     Tissue  was  normal. 

Other  organs  showed  nothing  of  special  importance. 

MICROSCOPICAL   EXAMINATION. 

The  tumor  proved  to  be  an  endothelial  sarcoma  of  the  spindle-celled 
type,  but  with  a  marked  tendency  to  preservation  of  the  endothelial 
type  of  cells  in  the  central  portions  of  the  cell  masses,  while  those  of 
the  outer  portions  were  spindle-shaped.  The  central  cells  when  dis- 
tinguishable were  seen  to  be  round  and  polygonal,  with  round  nuclei; 
the  outer  cells  had  oval  and  elongated  nuclei,  and  the  individual  cells 
were  hard  to  distinguish  except  in  very  thin  sections  and  when  mechan- 
ically separated.  A  feature  of  the  growth  was  the  separation  of  the 
cell  groups,  large  and  small,  by  delicate  bands  of  connective  tissue  appar- 
ently developed  from  spindle  cells  and  containing  slender  elongated 
nuclei.  The  blood  vessels  were  mainly  found  in  this  connective  tissue, 
though  a  few  small  simple  channels  were  found  among  the  cells.  The 
connective  tissue  strands  and  the  contained  bloodvessels  were  evidently 
as  essential  a  part  of  the  growth  as  the  cell  groups  themselves.     In  such 


42  GOVEBNMENT    HOSPITAL    B'OR    THE    INSANE. 

growths  as  this  the  two  unquestionably  bear  the  same  relation  to  each 

other  as  in  ordinary  alveolar  sarcoma,  both  being  neoplastic  in  origin. 
Hyaline  degeneration  was  advanced  in  this  growth,  involving  the  cell 
groups  of  all  shapes  and  sizes,  the  globular  cell  spherules,  and  the  blood 
vessels.  Some  masses  of  hyaline  change  involved  cell  groups  large 
enough  to  be  seen  with  the  naked  eye.  In  these  the  arrangement  of 
the  cells  coul.d  still  be  recognized  by  the  remains  of  cells  and  flattened 
nuclei.  In  some  of  the  hyaline  masses  occasional  small  blood  vessels, 
still  containing  corpuscles,  were  found  among  the  persistent  cell  nuclei. 
Many  of  the  globular  concentrically  striated  hyaline  bodies  were  found 
in  all  parts  of  the  growth.  These  we  now  believe  represent  a  later  stage 
of  degeneration  in  spherical  cell  groups,  though  all  traces  of  cells  may 
be  lost. 

The  blood  vessels  of  all  sizes  showed  advanced  hyaline  change.  Some 
were  nearly  obliterated,  showing  on  section  an  extremely  small  lumen 
containing  a  few  blood  cells.  Transverse  sections  of  completely  degen- 
erated vessels  in  which  no  lumen  could  be  seen  much  resembled  the 
small  hyaline  spherules.  Longitudinal  and  oblique  sections  of  degen- 
erated vessels  could  usually  be  distinguished  as  such  by  the  remains 
of  the  lumen  containing  red  corpuscles.  The  hyaline  substance  into 
which  the  elements  of  the  growth  were  transformed  was  perfectly 
homogeneous  when  complete  change  had  occurred;  but  in  most  of  the 
cell  groups  thus  altered  faint  concentric  or  wavy  lines  indicated  the 
grouping  of  the  elements,  and  in  the  hyaline  vessel  walls  extremely 
faint  striations  could  usually  be  seen.  (In  the  pen  drawings  fine  stip- 
pling had  to  be  used  to  represent  the  hyaline  material,  but  in  the  sec- 
tions it  showed  no  granulations  with  medium  powers.)  In  some  parts 
of  the  tumor  h\*aline  change  had  extended  to  nearl\T  all  the  elements, 
and  calcification  had  taken  place  in  many  of  the  masses.  It  is  this 
later  change  which  gives  the  gritty  feel  to  the  tissue  and  has  caused 
the  term  "  psammoma  "  to  be  improperly  used  for  these  tumors. 

In  fig.  24  I  have  given  the  general  structure  of  the  growth  with 
hyaline  cell  groups  and  blood  vessels.     Fig.  25  shows  some  of  the . 
details  under  a  higher  amplification. 

CASE    1582. 
SPINDLE-CELLED    SARC03IA    OF   THE    DURA    MATER. 

D.  K. ;  aged  81  }rears;  male;  white;  soldier;  nativity,  Germany. 
Mental  disease,  senile  dementia;  duration,  one  year.  The  patient  was 
quite  feeble,  being  unable  to  move  without  assistance,  and  showed 
advanced  dementia.  His  pulse  was  rapid;  he  had  cardiac  hypertrophy 
and  valvular  murmurs  were  present  at  mitral  and  tricuspid  orifices. 
Examination  of  the  urine  showed  albumen,  casts,  and  some  pus  cells. 
He  showed  rapidly  increasing  muscular  enfeeblement  and  became 
more  stuporous  until  death  occurred. 

So  far  as  could  be  learned  there  were  no  symptoms  of  intracranial 
tumor,  and  it  is  probable  that  being  of  slow  growth  and  situated  as  it 
was  in  the  outer  and  lower  portion  of  the  temporal  lobe,  no  appre- 
ciable effects  were  produced.  The  dementia  and  even  the  muscular 
enfeeblement  in  a  man  of  advanced  years  could  scarcely  be  attributed 
to  the  presence  of  the  tumor;  and  the  stupor  was  probably  in  part  due 
to  the  impairment  of  the  kidneys,  and  in  part  to  the  compression  of 
the  brain  from  the  coexisting  hematoma. 


GOVERNMENT    HOSPITAL    FOR   THE    INSANE.  43 

Autopsy  fourteen  hours  after  death.  Body  small  and  somewhat 
emaciated;  marked  lividity  of  dependent  portions. 

Cranium. — Diameters  of  skull  at  line  of  section  were  1\  by  6  inches. 
Calvaria  rather  thick;  sutures  distinct;  shape  symmetrical;  dura  mater 
firmly  adherent  to  the  bone.  On  both  sides  of  the  convexity  and 
extending  to  the  base  was  a  thick  false  membrane  of  hemorrhagic 
internal  pachymeningitis.  Over  the  superior  portions  the  neo-mem- 
brane  was  separated  into  two  layers  with  a  large  effusion  of  blood 
between  them.  There  was  but  little  increase  of  dural  tension  and 
perhaps  slight  compression  of  the  brain  fry  the  hematoma. 

Brain:  Weight,  1,240  grams.  In  the  deepest  portion  of  the  left 
middle  cerebral  fossa  was  a  large  tumor  which  had  originated  from 
the  dura  mater  and  had  penetrated  the  base  of  the  temporal  lobe. 
The  growth  had  to  be  dissected  from  the  surface  of  the  dura  mater  in 
order  to  remove  it  with  the  brain,  and  the  adherent  dural  surface  was 
somewhat  roughened  and  eroded,  and  the  bone  beneath  was  slightly 
irregular.  The  tumor  was  nearly  circular  in  outline  and  hemispheri- 
cal in  shape,  the  outer  or  dural  surface  being  flattened  and  adherent 
over  the  whole  extent  of  the  growth.  It  had  the  usual  appearances 
of  endothelial  sarcomata  of  the  dura;  it  was  about  an  inch  and  a  half 
in  longest  diameter,  and  had  penetrated  the  brain  to  the  depth  of  an 
inch.  Partial  enucleation  of  the  tumor  showed  that  the  brain  was 
penetrated  mechanically  by  the  growth  and  not  by  infiltration  of  its 
tissue.  The  tumor  was  reddish  gray  in  color,  and  apparently  more 
vascular  than  some  tumors  of  the  class.  The  left  hemisphere  was  not 
incised  at  the  time  of  examination;  the  right  half  showed  no  lesions  of 
the  interior.  The  convolutions  were  moderately  shrunken;  basal  arte- 
ries showed  a  few  patches  of  atheroma. 

Thorax. — Limited  pleuritic  adhesions  on  both  sides. 

Lungs:  Weight  of  right,  550  grams;  left,  630  grams.  The  organs 
were  oedematous  throughout,  showed  some  emphysema  of  the  anterior 
margins  and  some  hypostatic  congestion  of  the  posterior  portions. 

Heart:  Weight,  350  grams.  The  tricuspid  orifice  showed  some 
incompetency;  the  aortic  valves  were  thickened  and  calcareous;  the 
mitral  valve  was  thickened,  and  had  some  old  vegetations  at  the  line  of 
contact  of  the  segments.  At  the  apex  of  the  left  ventricle  the  muscle 
was  mottled  with  patches  of  chronic  myocarditis.  The  aorta  showed 
slight  atheroma  of  the  arch. 

Abdomen. — The  spleen  weighed  120  grams;  capsule  wrinkled  and 
thickened  in  patches  by  cartilaginoid  tissue.     Pulp  moderately  soft. 

Kidneys:  Weight  of  each,  120  grams.  Capsules  were  adherent; 
surfaces  granular;  cortical  tissue  a  little  pale  and  swollen;  a  few  small 
cysts  on  the  surfaces.     Urinary  bladder  normal. 

Liver:  Weight,  1,200  grams.  Tissue  was  apparently  normal.  Gall- 
bladder normal. 

Stomach:  Intestines  and  other  abdominal  organs  showed  nothing 
abnormal. 

MICROSCOPICAL   EXAMINATION. 

The  tumor  proved  to  be  a  spindle-celled  endothelial  sarcoma,  as 
indicated  by  the  naked-eye  appearances.  The  spindle  cells  were 
arranged  in  whorls  and  bands  similar  to  many-  tumors  of  the  class 
already  described,  and  a  small  number  of  hyaline  and  partly  calcified 
spherules  were  found.     Hyaline  degeneration  was  a  marked  feature 


44  GOVERNMENT    HOSPITAL    FOR    THE    INSANE. 

in  this  growth,  affecting  especially  the  blood-vessel  walls  and  bands  of 
connective  tissue.  The  vessels  were  very  numerous  in  some  parts  of 
the  growth, and  nearly  all  were  hyaline  and  greatly  thickened,  though 
as  a  rule  the  lumen  was  preserved  and  tilled  with  blood.  Some  of  the 
vessels  were  surrounded  by  many  layers  of  spindle  cells,  arranged 
circularly,  and  sometimes  partly  hyaline.  In  tumors  of  this  class  it 
is  not  uncommon  to  find  blood  vessels  surrounded  by  a  thick  layer  of 
concentrically"  arranged  spindle  cells,  which  may  undergo  hyaline 
degeneration  and  result  in  thick  hyaline  walls,  such  as  are  shown  in 
fig.  28. 

The  connective  tissue  was  relatively  abundant  in  this  growth,  espe- 
cially around  the  vessels.  The  mature  fibrous  tissue  found  in  tumors 
of  this  elass  must  be  considered  as  an  essential  constituent,  as  it  is  in 
ordinary  sarcomata  and  most  other  tumors.  The  exact  histogenesis 
of  the  connective  tissue  in  these  tumors  is  hard  to  demonstrate,  but 
it  seems  reasonable  to  conclude  that  it  is  of  the  same  origin  as  the 
tumor  cells,  and  its  proliferation  is  due  to  the  same  causes. 

Examination  of  the  boundary  between  the  tumor  and  the  brain 
tissue  showed  what  appeared  to  be  remnants  of  the  pia  mater  incor- 
porated with  the  tumor,  but  still  recognizable  by  the  fully  formed 
blood  vessels  and  mature  connective  tissue. 

The  brain  substance  showed  a  border  of  degenerated  tissue,  but  at 
a  slight  depth  no  alteration  due  to  the  presence  of  the  tumor  was 
perceptible. 

General  microscopic  examination  of  the  brain  has  not  yet  been  made, 
and  the  histological  study  of  the  other  organs  was  deemed  unimportant. 

CASE  1178. 

SPINDLE-CELLED   ENDOTHELIAL   SARCOMA   OF    THE    DURA   MATER,  PENE- 
TRATING  THE   BRAIN. 

J.  E. ;  aged  68;  colored;  widower;  laborer;  late  soldier;  mental 
disease,  senile  dementia;  duration,  three  and  one-half  years.  The 
patient  was  admitted  to  the  Western  Branch,  National  Home  for 
Disabled  Volunteer  Soldiers,  October  2,  1893,  with  left  hemiplegia, 
convulsions,  and  was  almost  helpless.  He  was  admitted  to  the  insane 
ward  April  27,  1S97,  with  a  history  of  advanced  dementia,  complete 
left  hemiplegia,  and  general  prostration. 

On  May  4,  1897,  he  was  admitted  to  the  Government  Hospital  for 
the  Insane  with  the  above  mental  and  physical  symptoms  somewhat 
advanced.  May  30,  1897  he  died  suddenly,  apparently  from  an 
apoplectiform  seizure.  From  the  recorded  symptoms  the  tumor  had 
apparent!}7  existed  over  three  and  one-half  }Tears. 

Autopsy  seventeen  hours  after  death;  body  fairly  well  nourished; 
rigor  mortis  present;  signs  of  commencing  decomposition  over  lower 
part  of  abdomen. 

Cranium. — Antero-posterior  diameter  of  skull,  1\  inches;  trans- 
verse diameter,  5i  inches.  The  skull  was  rather  thick  and  dense; 
shape  asymmetrical,  the  occipital  protuberance  being  situated  to  the 
left  of  tlie  median  line.  Sutures  visible  externally,  but  indistinct  in 
inner  table.  On  the  right  side  in  the  parietal  region  a  marked  eleva- 
tion existed  on  the  inner  surface.  There  were  no  signs  of  external 
injury,  and  the  elevation  of  the  inner  surface  was  probably  related 
to  the  dural  growth  afterward  described.    Section  of  the  bone  through 


GOVERNMENT    HOSPITAL    FOR    THE    INSAXK.  45 

this  protuberance  showed  nothing  abnormal  but  unusual  vascularity 
of  the  tissue;  both  tables  and  the  diploe  were  intact  and  the  thickening 
seemed  to  be  mainly  of  the  cancellous  tissue. 

Brain:  Weight  of  right  hemisphere  with  the  tumor,  V.)\  ounces 
(545.73  grams);  left  hemisphere  18  ounces  (510.3  grams);  cerebellum, 
pons,  and  medulla,  5£  ounces  (155.92  grams).  Before  opening  the 
dura  mater  a  depression  was  observed  in  its  outer  surface  in  the 
parietal  region  corresponding  with  the  elevation  of  the  inner  surface 
of  the  skull,  and  adhesions  to  the  bone  were  firmer  here  than  elsewhere. 
On  lifting  the  dura  from  the  brain  a  large  tumor  was  found  beneath  it 
embedded  in  the  brain,  but  apparently  raised  above  its  general  surface 
by  the  dropping  away  of  the  soft  and  cedematous  cerebral  substance. 
The  tumor  was  adherent  to  the  dura,  so  that  the  membrane  was  left 
attached  to  it.  The  growth  was  3^  inches  broad  in  its  antero-posterior 
diameter;  3^  inches  in  its  vertical  diameter,  and  was  exactly  If  inches 
in  thickness.  The  growth  occupied  almost  the  whole  of  the  parietal 
lobe,  had  crowded  forward  the  central  convolutions  and  the  fissure  of 
Rolando,  and  the  ascending  parietal  convolution  was  encroached  upon 
and  nearly  destroyed  by  the  pressure  of  the  tumor.  It  extended  ver- 
tical^7 from  the  upper  border  of  the  posterior  end  of  the  fissure  of 
Sylvius  to  the  median  edge  of  the  hemisphere,  and  antero-posteriorly 
from  near  the  fissure  of  Rolando  to  the  anterior  border  of  the  occipital 
lobe.  A  section  was  made  through  the  center  of  the  growth,  and  it 
was  then  found  that  the  tumor  had  penetrated  the  brain  as  far  as  the 
ependyma  of  the  ventricles  and  nearly  to  the  median  surface  of  the 
hemisphere.  On  the  median  surface  the  tumor  had  not  reached  to 
the  cortex,  though  probably  pressure  had  destroyed  brain  function 
over  the  advancing  growth.  The  quadrate  lobe  was  greatly  damaged 
and  the  paracentral  lobule  was  practically  destroyed. 

The  consistence  of  the  tumor  was  quite  firm,  but  the  brain  tissue 
surrounding  it  was  soft  and  pulpy,  so  that  the  brain  had  to  be  handled 
with  extreme  care  to  avoid  enucleation  of  the  tumor  while  making  the 
necessary  sections.  The  growth  had  firm  adhesions  to  the  dura  mater 
and  it  had  apparently  carried  with  it  the  pia  mater  as  it  penetrated  the 
brain,  and  traces  of  membrane  and  even  cortex  could  be  distinguished 
around  the  boundaries. 

The  tumor  tissue  had  a  reddish-gray  color;  the  surface  looked  a 
little  granular,  but  no  gritty  particles  could  be  seen  or  distinguished 
by  cutting.  Bands  of  connective  tissue  could  be  distinguished  radiating 
from  the  origin  of  the  growth  and  intersecting  it  in  every  direction. 

The  pia  mater  of  the  left  hemisphere  was  cloudy  over  the  convexhYy, 
and  the  convolutions  showed  the  effects  of  pressure.  There  was  some 
atrophy  of  the  convolutions  and  oedema  of  the  pia,  but  not  as  much  as 
usual  in  cases  of  senile  insanity  due  to  other  causes.  The  arteries  at 
the  base  showed  no  signs  of  disease.  There  were  no  gross  lesions  in 
cerebellum,  pons,  and  medulla.     Cord  showed  no  evidences  of  disease. 

Thorax. — Pleuritic  adhesion  on  both  sides.  The  lungs  were  cedem- 
atous and  full  of  blood  posteriorly.  Weight  of  the  right,  22  ounces 
(623.7  grams);  of  the  left,  20 -ounces  (567  grams).  Some  muco-puru- 
lent  secretion  poured  from  the  bronchi  on  section. 

Heart:  Weight,  11^  ounces  (326  grams).  A  thin  band  of  connective 
tissue  stretched  across  the  entrance  of  the  pulmonary  artery,  appar- 
ently a  congenital  malformation.  The  pulmonary  valves  were  normal; 
the  tricuspid  valve  was  a  little  thickened  at  its  edges.     The  aortic 


46  GOVERNMENT    HOSPITAL    FOR    THE    INSANE. 

valves  were  slightly  thickened  and  had  some  small  chronic  vegetations 
at  line  of  contact;  mitral  valve  was  slightly  thickened  at  its  edges. 
Aorta  showed  an  early  stage  of  atheroma;  coronary  vessels  not 
diseased. 

Abdomen. — The  spleen  weighed  3f  ounces  (106.3  grams).  Pulp 
firm;  rather  pale;  capsule  wrinkled. 

Kidneys:  Weight  of  right,  4£  ounces  (120.48  grams);  left,  4  ounces 
(113.4  grams).  The  capsules  were  not  adherent;  surfaces  showed  a 
few  small  cysts;  in  other  respects  the  organs  seemed  normal.  Urinary 
bladder  was  normal. 

Liver:  Weight,  37i  ounces  (1,056  grams).  Left  lobe  of  liver  very 
small;  tissue  seemed  normal;  gall-bladder  contained  2  fluid  ounces  of 
bile. 

The  other  abdominal  organs  seemed  normal. 

MICROSCOPICAL  EXAMINATIONS. 

Tumor  of  brain:  The  growth  consisted  mainly  of  delicate  spindle 
cells  with  prominent  oval  nuclei  and  clear  cell  protoplasm.  The  cells 
were  closely  applied  to  each  other  in  the  dense  cell  masses,  so  that  the 
contours  of  the  cells  were  hard  to  distinguish,  but  were  easity  seen  in 
the  looser  portions  of  the  growth.  The  cells  were  arranged  in  wavy 
bands,  running  in  every  direction,  and  in  concentrically  grouped  cell 
masses,  though  this  was  not  a  prominent  feature  in  the  growth.  No 
hyaline  cell  groups  were  found  in  the  sections  examined,  though  they 
are  probably  formed  in  some  part  of  the  growth,  as  they  are  very 
common  in  growths  of  this  class.  Large  bands  of  connective  tissue 
intersected  the  tumor  tissue  in  eveiy  direction.  In  some  places  this 
tissue  was  loose  and  fibrous  and  blended  b}r  various  stages  of  tissue 
development  into  the  spindle-cell  tissue;  in  other  regions  the  tissue 
was  dense,  almost  devoid  of  nuclei  and  apparently  hyaline.  It  seemed 
evident  to  the  writer  that  this  fibrous  tissue  was  a  development  from 
the  spindle-celled  structure  and  as  essential  a  part  of  the  tumor  as  the 
cell  tissue  itself.  The  connective-tissue  bands  contained  many  large 
blood  vessels,  often  with  thick  and  h}Taline  walls,  and  many  blood 
channels  without  definite  walls  other  than  a  ]nyev  of  endothelium  sep- 
arating the  channel  from  the  surrounding  tissue.  In  some  places 
these  channels  were  very  numerous,  giving  almost  the  appearance  of 
angioma.  Some  of  the  vessels  were  completely  obliterated  by  hyaline 
changes  in  all  parts  of  the  growth.  In  the  cellular  portion  of  the 
tissue  blood  vessels  were  not  so  numerous  nor  so  large.  Some  of 
these  were  thick  walled  and  hyaline,  some  were  mere  channels  lined 
with  flattened  cells,  and  some  were  surrounded  by  many  layers  of 
spindle  cells. 

Brain:  The  brain  cells  were  in  an  advanced  stage  of  degeneration; 
in  some  cases  clumps  of  brownish-3Tellow  granules  represented  all  that 
was  left  of  the  degenerated  cells.  The  perivascular  and  pericellular 
spaces  were  very  large;  some  of  the  blood  vessels  were  curved,  and 
hsematoidin  granules  were  found  along  their  walls.  The  nerve  cells 
of  medulla,  cord,  and  cerebellum  were  pigmented  and  granular. 

The  lungs  were  not  examined  with  the  microscope.  The  liver  was 
normal  except  slight  engorgement  of  the  capillaries.  The  spleen 
showTed  the  effects  of  chronic  congestion  in  the  enlargement  and  dis- 
tinctness of  the  venous  sinuses. 


GOVERNMENT    HOSPITAL    FOR    THE    INSANE.  47 

The  kidneys  were  moderately  full  of  blood;  there  was  some  crum- 
bling of  the  inner  portions  of  the  cells  of  the  convoluted  tubules,  and 
a  few  small  cysts  with  colloid  contents  were  found. 

CASE  789. 

SPINDLE-CELLED    SARCOMA    OF    DURA    MATER. 

L.  F. ;  aged  52;  married;  captain,  U.  S.  Marine  Corps;  nativity, 
United  States.  Mental  disease,  chronic  dementia;  duration,  one  year 
and  eight  months.  The  patient  had  a  certain  degree  of  dementia  when 
admitted,  which  deepened  toward  the  close  of  life.  He  had  halluci- 
nations of  hearing,  taste,  smell,  and  sight  sensations  were  present, 
though  he  was  totally  blind.  His  prevailing  mental  tone  was  depres- 
sion, though  he  was  occasionally  cheerful.  He  had  some  delusions  of 
persecution,  and  was  apprehensive  of  danger  to  himself;  at  times  when 
influenced  )ry  these  delusions  he  became  irritable  and  abusive.  Toward 
the  end  he  became  much  demented,  and  finally  he  had  a  convulsive 
attack  which  terminated  in  coma  and  death. 

The  physical  symptoms  were  not  prominent;  there  seemed  to  be  some 
impairment  of  muscular  power  on  the  left  side;  his  speech  was  thick  at 
times;  there  was  some  vertigo  and  occasional  vomiting.  Headache  was 
not  a  prominent  symptom,  though  occasionally  he  complained  of  pain. 

Autopsy  twelve  hours  after  death.  Body  well  nourished;  rigor  mor- 
tis present;  lividity  of  the  face,  neck,  and  dependent  portions  of  body. 

Cranium. — Antero-posterior  diameter  of  skull,  7i  inches;  trans- 
verse, 6  inches.  The  skull  was  of  the  usual  thickness,  symmetrical 
and  the  sutures  were  normal.  The  dura  mater  was  easily  removed  from 
the  bone  over  the  superior  portions  of  the  calvaria,  but  at  the  anterior 
extremity  of  the  left  middle  cerebral  fossa,  over  the  right  orbital  plate 
of  the  frontal  bone,  and  over  the  greater  part  of  the  right  middle  cere- 
bral fossa,  the  membrane  adhered  firmly,  and  a  considerable  degree  of 
roughening  or  absorption  of  the  bone  had  taken  place  beneath  it.  On 
the  right  side  of  the  crista  galli  an  opening  communicated  with  the 
ethmoidal  cells,  and  on  the  right  side  of  the  frontal  bone  a  similar 
opening  communicated  with  the  frontal  sinus.  Into  these  openings 
portions  of  softened  cerebral  substance  had  been  forced,  probably  by 
intracranial  pressure.  The  pia  mater  had  been  pressed  in  with  the 
brain  substance,  and  by  its  vessels  kept  the  cerebral  hernias  alive. 
At  the  site  of  the  dural  adhesions  the  pia  mater  and  brain  cortex  were 
firmly  adherent  to  the  inner  surface  of  the  dura,  so  that  it  was  impos- 
sible to  remove  the  brain  without  considerable  laceration. 

Brain:  Weight  of  left  hemisphere,  28i  ounces  (817.97  grams);  right 
hemisphere,  27i  ounces  (779.62  grams);  cerebellum,  pons,  and  medulla, 
6f  ounces  (191.36  grams).  The  pia  mater  was  oedematous;  veins  mod- 
erately full  of  blood;  membrane  adherent  to  the  dura  and  cortex  at 
points  mentioned  above.  Arteries  at  the  base  normal  in  arrangement 
and  free  from  disease.  The  convolutions  were  flattened  against  the 
skull,  especially  over  the  anterior  portion  of  the  right  hemisphere. 
The  orbital  surface  of  the  right  frontal  lobe  was  greatly  softened,  so 
that  hernias  of  the  brain  had  taken  place  through  the  openings  in  the 
dura  and  inner  table  of  the  skull.  Over  the  whole  adherent  surface 
the  brain  cortex  was  torn  by  removal  of  the  pia  mater.  The  anterior 
extremity  of  the  left  temporal  lobe  was  extensively  softened,  and  cor- 
tex, pia,  and  dura  were  adherent  together. 


48  GOVERNMENT    HOSPITAL    FOR   THE    INSANE. 

On  the  right  side,  at  the  entrance  of  the  fissure  of  Sylvius  was  a 
large  tumor  nearly  two  inches  in  diameter  which  had  probably  originated 

hi  the  dura  mater,  as  it  was  firmly  adherent  to  that  membrane.  It 
had  penetrated  the  brain  deeply,  and  had  encroached  upon  and  pressed 
aside  the  third  frontal  convolution, the  lower  portion  of  the  ascending 
frontal,  the  anterior  portions  of  the  three  temporal  convolutions,  and 
had  invaded  and  pressed  upon  the  island  of  Roil.  The  pressure  had 
not  appreciably  affected  the  basal  ganglia  and  capsules,  as  it  was  mainly 
in  front  ot  these  structures. 

The  tumor  was  of  a  reddish-gray  color,  somewhat  rough  externally, 
and  seemed  to  have  a  complete  capsule.  On  section  the  growth  pre- 
sented about  the  same  color.  It  was  soft  and  seemed  to  he  quite 
va>eular.  The  sections  showed  that  though  the  growth  was  adherent 
to  the  pia  mater  over  the  portions  of  brain  it  had  invaded,  the  cortex 
was  still  distinguishable  in  advance  of  tumor,  and  even  the  pia  mater 
could  be  seen  between  the  tumor  and  the  cortex.  In  the  vicinity  of  the 
tumor  the  brain  tissue  was  very  soft,  but  no  destruction  of  tissue  had 
been  caused  by  the  invasion  of  the  tumor. 

The  brain  substance  generally  was  soft,  (edematous,  and  rather  pale. 
There  were  no  gross  lesions  of  the  interior  of  brain,  cerebellum,  pons, 
and  medulla.  The  optic  nerves  and  tracts  were  atrophied  and  gray 
in  color.  The  right  olfactory  nerve  had  been  destroyed  bw  the  soften- 
ings in  the  vicinity.  The  other  cranial  nerves  seemed  normal  to  the 
naked  eve.  A  portion  of  the  cervical  spinal  cord  removed  with  the 
brain  seemed  normal. 

Other  organs  not  examined. 

MICROSCOPICAL    EXAMINATION. 

The  tumor  consists  almost  entirely  of  spindle  cells  in  bands  running- 
in  every  direction,  and  some  whorls,  or  concentric  arrangements  of 
the  cells;  but  these  are  not  so  perfect  as  in  some  tumors  of  this  class. 
The  arrangement  of  the  cells  is  much  looser  than  in  some  similar 
tumors,  and  there  is  a  considerable  quantity  of  delicate  connective 
tissue  throughout  the  growth. 

A  striking  feature  in  this  tumor  is  the  large  number  of  huge  vessels 
with  thick  fibrous  walls  which  in  the  majority  have  undergone  hyaline 
degeneration.  Vessels  with  muscular  tissue  in  their  walls  have  not 
been  found,  though  spindle-cell  elements  are  certainly  found  in  the 
walls  among  the  fibrous  tissue.  In  many  of  the  vessels  nearly  the  whole 
wall  is  converted  into  a  hyaline,  glassy  material  which  stains  lightly  in 
carmine,  and  which  I  have  supposed  to  be  hyalin.  Another  peculiarity 
in  these  vessels  is  the  cellular  thickening  of  the  inner  coat,  wThich  much 
resembles  the  condition  seen  in  endarteritis.  A  singular  condition  is 
seen  in  man}T  of  the  large  vessels  which  is  not  clearty  understood  by 
the  writer.  The  endothelial  lining  is  entirely  separated  from  the  vessel 
wall,  and  blood  intervenes  between  the  the  loosened  endothelial  cells 
and  the  vessel  wall.  As  the  sections  were  cut  by  the  interstitial 
embedding  methods  and  fixed  to  the  slides  before  re  noving  the  infil- 
trating material,  it  must  be  concluded  that  such  was  the  ante-mortem 
condition  of  the  vessels. 

A  few  large  hyaline  globes  are  found  in  the  sections  and  great  num- 
bers of  small  hyaline,  sometimes  concentrically  striated,  round,  or  oval 
bodies  are  found  in  every  part  of  the  growth.  They  seem  to  be  unusu- 
ally numerous  in  the  vicinity  of  the  vessels,  and  they  are  often  found 


GOVERNMENT    HOSPITAL    FOR    THE    INHANE.  49 

in  close  proximity  to  the  hyaline  material  in  the  vessel  walls.  In  some 
instances  it  seemed  possible  to  resolve  certain  portions  of  the  hyaline 
change  in  the  vessel  walls  into  these  bodies.  The  similarity  in  appear- 
ance between  the  large  hyaline  globes  and  the  small  spherules  suggests 
that  thej^  may  be  similar  in  nature  and  origin. 

In  this  and  in  other  descriptions  of  similar  bodies  the  term  hyaline 
is  used  as  descriptive  of  the  appearances  rather  than  indicating  any 
definite  composition,  for,  though  it  is  probable,  it  is  not  proven  that 
thejr  are  the  same  in  composition  as  the  degeneration  product,  "hya- 
lin,"  described  by  Recklinghausen.  By  the  use  of  iodine  and  other 
staining  agents,  I  am  quite  satisfied  that  the  change  in  the  vessels  and 
the  nature  of  the  glassy  bodies  is  not  amyloid. 

The  brain  generally  shows  little  of  interest.  The  tissue  in  the  vicin- 
ity  of  the  tumor  shows  some  of  the  effects  of  pressure.  The  pericellu- 
lar spaces  are  flattened  and  the  cells  are  compressed.  The  nerve-cells 
show  a  moderate  degree  of  j^ellow  granular  degeneration  of  the  cell 
bodies,  though  the  nuclei  are  alwa}^s  distinct.  The  blood  vessels  are 
somewhat  tortuous;  pigment,  and  sometimes  a  slight  increase  in  the 
perivascular  nuclei,  may  be  seen. 

The  brain  hernias  are  composed  of  mechanically  disarranged  brain 
tissue,  with  the  products  of  softening  and  hemorrhage.  The  blood 
vessels  carried  in  with  the  pia  mater  still  retain  their  contents,  and 
their  walls  show  evidence  of  inflammatory  changes.  Some  of  the  ves- 
sels in  the  brain  hernias  show  glass}^  change  in  their  walls.  Many 
spider  cells,  large  fatty  epithelioid  cells,  and  groups  of  round  cells  are 
found  in  different  parts  of  the  sections. 

The  cerebellum,  pons,  and  medulla  show  nothing  of  special  interest. 

CASE   1130. 

HEMORRHAGIC    SPINDLE-CELLED     SARCOMA    OF    THE     CEREBELLUM    AXD 
MULTIPLE    SOFT    FIBROMATA    OF   THE    SKIN. 

A.  B.;  aged  61;  white;  single;  laborer;  late  soldier;  nativity,  Penn- 
sylvania. Mental  disease,  chronic  epileptic  mania;  duration  over  four 
years.  The  patient  was  admitted  to  the  Central  Branch  National 
Home  for  Disabled  Volunteer  Soldiers  September  2,  1892.  Medical 
history  of  chronic  rheumatism,  hemmorhoids,  and  epileptic  seizures. 
He  had  fits  of  violence  at  intervals  of  four  or  five  days,  in  which  he 
tried  to  injure  his  attendants,  break  furniture,  etc.  Mental  power 
weak  when  admitted  to  the  Soldiers'  Home. 

On  admission  to  the  Government  Hospital  for  the  Insane,  May  1, 
1893,  he  was  weak;  was  soon  confined  to  his  bed;  moderately  demented; 
memory,  perceptions,  and  comparative  faculty  all  impaired,  but  he 
could  talk  rationally,  for  the  most  part.  He  had  no  delusions,  but 
showed  progressive  dementia,  with  occasional  attacks  of  impulsive 
f  ury,  in  which  he  would  beat  his  bed  and  attack  an3Tone  coming  within 
his  sight  or  reach,  at  the  same  time  uttering  inarticulate  cries  of  rage. 
These  furors  were  of  brief  duration,  and  were  followed  by  short  peri- 
ods of  confusion,  with  rapid  breathing  from  excitement  and  exertion, 
to  pass  into  the  usual  state  of  quiet  dementia. 

The  whole  body  was  covered  by  soft  fibrous  tumors  of  the  skin, 
varying  in  size  from  the  smallest  visible  nodule  to  the  size  of  a  wal- 
nut, and  in  certain  regions  the  skin  hung  in  pendulous  masses  of  the 

21618—03 1 


50  GOVERNMENT    HOSPITAL    FOR    THE    INSANE. 

same  character  as  the  tumors.  His  general  health  was  fair,  aside  from 
weakness,  and  there  was  no  evidence  of  organic  disease  other  than  of 
the  brain  and  the  dermal  growths,  lie  had  no  paralysis  nor  altered 
sensations  other  than  impairment  of  acuteness,  though  the  mental 
dullness  of  the  patient  made  the  physical  examination  difficult. 

The  patellar  reflex  was  somewhat  exaggerated.  There  was  no 
appreciable  affection  of  the  cranial  nerves;  no  headache;  no  neuralgic 
pain;  sight  was  not  appreciably  affected.  lie  had  occasional  attacks 
of  vomiting,  and  suffered  from  vertigo  on  assuming  the  erect  posture. 

No  convulsion  occurred  for  more  than  a  year  after  his  transterrence 
to  the  Toner  Building-,  August  14,  1894,  except  the  psychical  attacks 
of  rage  and  violence.  In  the  summer  of  1896  the  first  epileptic  con- 
vulsion occurred,  after  which  the  psychic  attacks  were  completely 
superseded  by  those  of  distinct  epileptic  character.  Dementia  pro- 
gressed rapidly  during  the  last  few  months  of  his  life,  and  death 
occurred  suddenly  November  13,  1896. 

The  progressive  impairment  of  the  cerebral  functions  and  the  degree 
of  physical  and  mental  failure  suggested  organic  disease  of  the  brain, 
but  otherwise  there  were  no  symptoms  to  differentiate  the  case  from 
one  of  chronic  epilepsy. 

Autopsy  six  hours  after  death:  Rigor  mortis  not  developed.  The 
whole  body  was  covered  with  soft  fibrous  growths  of  the  skin,  which 
varied  in  size  from  an  inch  in  diameter  to  a  pin-head  size.  Some  of 
the  growths  were  pedunculated;  all  were  very  soft;  some  were  a  little 
darker  than  the  surrounding  skin,  and  some  the  same  color.  The 
forehead  was  thickly  studdied  with  the  growths,  and  they  were  espe- 
cially numerous  on  the  arms.  Over  the  right  gluteal  region,  outer 
and  lowTer  portion  of  right  thigh,  and  outer  aspect  of  right  leg  below 
the  knee,  the  skin  seemed  to  hang  in  large  masses,  which  appeared  to 
be  of  the  same  character  as  the  tumors.  On  the  right  leg,  just  below 
the  knee,  was  a  somewhat  more  tumor-like  mass  nearly  3  inches  in 
diameter.  The  large  pendulous  masses  are  of  the  same  nature  as  the 
circumscribed  growths,  but  are  less  sharply  defined  from  the  normal 
skin.  By  some  pathologists  they  are  regarded  as  continuous  out- 
growths, closely  allied  to  elephantiasis;  by  others  the}''  are  believed  to 
be  diffuse  hypertrophies  of  the  skin.  They  are  frequently  associated 
with  soft  fibromata  of  the  skin,  and  must  be  regarded  as  due  to  the 
same  cause. 

Section  of  the  tumors  showed  them  to  be  very  soft  and  succulent, 
somewhat  less  fibrous  than  the  dermis  and  a  little  less  elastic,  so  that 
the  tumor  tissue  projected  from  the  cut  surface  as  the  skin  retracted. 
In  hardening,  the  skin  over  the  tumors  became  greatly  wrinkled  and 
shrank  away  from  the  tumor  mass,  and  the  whole  growth  was  greatly 
reduced  in  size. 

Cranium,. — Antero-posterior  diameter  of  skull,  7f  inches;  trans- 
verse, 6  inches.  Skull  a  little  thicker  than  the  average;  shape  sym- 
metrical; sutures  rather  indistinct.  On  the  outer  surface  were  a 
number  of  small  nodular  exostoses  slightly  raised  from  the  surface  of 
the  bone.  The  dura  mater  was  not  abnormally  adherent  to  the  bone, 
except  over  a  small  area  in  the  anterior  part  of  the  left  cerebellar 
fossa,  where  it  was  also  adherent  to  a  tumor  which  was  embedded  in 
the  left  hemisphere  of  the  cerebellum.  The  general  surface  of  the 
dura  at  this  situation  was  smooth,  and  there  were  no  indications  of  the 
growth  having:  originated  from  the  dura  mater. 


GOVERNMENT    HOSPITAL    FOR   THE    INSANE.  51 

Brain. — Weight  of  right  hemisphere,  23£  ounces  (666.2  grams);  left 
hemisphere,  23f  ounces  (673.3  grams);  cerebellum,  pons,  and  medulla 
with  the  tumor,  8  ounces  (226.8  grams).  The  subdural  space  was  dry 
and  there  was  a  marked  degree  of  intracranial  pressure  indicated  by 
flattening  of  the  convolutions  against  the  dura  over  the  whoJe  con- 
vexity. Embedded  in  the  outer  anterior  part  of  the  left  cerebellar 
hemisphere  was  a  hemorrhagic  tumor  about  an  inch  and  a  half  in  its 
long  diameter  and  an  inch  and  a  quarter  in  transverse  diameter.  The 
growth  was  irregularly  oval  in  shape,  with  its  long  axis  parallel  with 
the  horizontal  plane  of  the  cerebellum.  Incision  into  the  growth 
showed  the  greater  part  of  the  mass  to  be  blood  clot,  the  remainder  of 
the  tumor  tissue  of  moderately  firm  consistence.  Though  the  blood 
had  coagulated  into  a  firm  clot,  it  did  not  appear  to  be  of  long  stand- 
ing, as  no  degenerative  changes  had  taken  place  in  the  blood.  A  firm 
capsule  had  retained  the  extravasation,  and  the  hemorrhage  did  not 
appear  to  have  added  much  to  the  size  of  the  growth.  It  was  there- 
fore supposed  to  consist  for  the  most  part  of  infiltrated  tissue,  and 
such  the  microscope  proved  it  to  be.  The  fifth  nerve  was  stretched 
over  the  superior  surface  of  the  tumor,  showing  that  it  started  at  the 
extreme  lower  and  anterior  portion  of  the  cerebellum.  The  pons  was 
displaced  toward  the  right,  and  the  growth  encroached  upon  the 
seventh  and  eighth  nerves  at  the  upper  part  of  the  medulla.  Where 
the  growth  was  embedded  in  the  cerebellum  it  had  caused  loss  of  sub- 
stance and  some  softening,  as  may  be  seen  in  the  photographs. 

The  vessels  at  the  base  of  the  brain  were  not  diseased;  ventricles 
greatly  dilated;  brain  substance  cedematous  and  soft;  perivascular 
spaces  enlarged;  no  gross  lesions  in  any  part  of  cerebrum,  except 
some  induration  of  the  hippocampi  and  uncinate  gyri. 

The  cerebellum,  pons,  and  medulla  were  preserved  intact  as  a 
museum  specimen,  and  therefore  were  not  examined  by  section. 

Thorax. — Some  brnds  of  chronic  pleuritic  adhesions  were  found  on 
the  right  side.  At  the  apices  were  some  old  pleural  scars  and  some 
small  grajdsh  nodules,  supposed  to  be  tubercular  deposits.  Large 
hemorrhagic  areas  were  scattered  throughout  the  other  portions  of 
the  lungs.  The  left  lung  weighed  19  ounces  (538.6  grams);  the  right, 
24  ounces  (680.4  grams). 

Heart:  Weight,  12  ounces  (310.2  grams).  Pulmonary  valves  nor- 
mal; tricuspid  a  little  thickened;  aortic  valves  were  a  little  thickened 
and  showed  some  adhesion  to  each  other  at  their  attached  edges. 
Mitral  valve  slightly  thickened  at  its  edges.  Heart  muscle  firm;  aorta 
normal. 

Abdomen. — The  spleen  weighed  12i  ounces  (317.2  grams);  capsule 
wrinkled;  pulp  very  dark,  full  of  blood,  and  soft. 

Kidneys:  Weight  of  right,  li  ounces  (120.1  grams);  left,  If  ounces 
(131.6  grams).  The  organs  contained  more  blood  than  normal;  cap- 
sules slightly  adherent;  surfaces  showed  some  depressions  and  were  a 
little  granular;  cortex  was  somewhat  reduced  in  thickness.  The  uri- 
nary bladder  showed  some  hypertrophy  and  enlargement  of  the  middle 
lobe  of  the  prostate  gland. 

Liver:  Weight,  18£  ounces  (1,375.9  grams).  The  tissue  showed 
slight,  passive  congestion.  Gall-bladder  contained  a  small  quantity  of 
dark  bile. 

The  other  abdominal  organs  were  apparently  free  from  disease. 


52  GOVERNMENT    HOSPITAL    FOR    THE    INSANE. 

MICROSCOPICAL    EXAMINATION. 

Tumor  of  brain:  The  greater  portion  of  the  bulk  of  the  tumor  was 
composed  of  blood  and  tissue  so  infiltrated  with  blood  that  it  was  im- 
possible to  make  sections  of  it.  The  greater  part  of  the  tissue  which 
remained  outside  the  hemorrhagic  area  was  composed  of  spindle  cells 
in  close  proximity  to  each  other  arranged  in  wavy  or  curved  hands 
running  in  every  direction.  The  spindle  cells  were  delicate  and  closely 
applied  to  each  other,  so  that  it  was  difficult  to  see  the  cells  except  in 
very  thin  sections  and  where  accidentally  torn  apart,  and  the  direction 
and  arrangement  of  the  cells  was  mainly  indicated  by  the  nuclei. 
Some  fields  were  found  in  which  round  cells  predominated,  lying  among 
delicate  connective  tissue  fibrils.  These  fields  were  found  most  fre- 
quently near  the  seat  of  hemorrhage,  and  it  is  possible  that  many  of 
the  round  cells  were  leucocytes.  In  the  midst  of  masses  of  spindle- 
celled  tissue  groups  of  round  nuclei  were  often  found;  these  were  sup- 
posed to  be  transverse  sections  of  the  nuclei  of  spindle  cells.  In  the 
purely  cellular  portion  of  the  growth  no  connective  tissue  was  visible, 
but  in  certain  fields  the  process  of  fibrillation  was  far  advanced,  and 
in  some  of  the  round-cell  areas  the  intercellular  substance  was  distinctly 
fibrillated.  Some  areas  were  found  in  which  the  structure  resembled 
the  early  stages  of  granulation  tissue,  and  indeed  there  may  have  been 
some  reactive  inflammatory  tissue  formation.  The  structure  of  the 
growth  was  in  fact  very  confusing,  and  diagnosis  was  only  made  by 
examination  of  large  areas  composed  exclusively  of  spindle  cells.  The 
blood  vessels  in  the  cellular  tissue  were  of  the  type  found  in  all  sar- 
comata; they  had  imperfect  w7alls  composed  of  flattened  cells,  and  ran 
as  mere  channels  through  the  tissue;  in  a  few,  however,  hyaline  change 
had  thickened  the  walls  and  even  obliterated  the  lumen.  In  the  fibrous 
tissue  some  of  the  vessels  had  thick  fibrous  or  hyaline  walls  and  some 
were  mere  channels  in  the  tissue  lined  with  flattened  cells.  No  vessels 
with  perfectly  developed  walls  were  found  in  an}r  of  the  tumors  of  this 
class,  and,  in  fact,  it  seems  that  perfect  vessels  are  not  developed  in 
the  low  grade  of  connective  tissue  found  in  these  neoplastic  structures. 
Large  blood-channels  lined  with  flattened  cells  were  found  in  the  tissue 
adjoining  the  hemorrhagic  portion  of  the  growth.  The  tumor  undoubt- 
edly belongs  to  the  same  class  as  those  of  cases  1146  and  1178,  though 
the  whorl-like  arrangement  of  the  cells  was  not  so  perfect  and  no 
hyaline  cell  spherules  were  found.  Though  the  structure  of  the 
growth  was  somewhat  perplexing  and  the  origin  uncertain,  it  was 
diagnosed  a  spindle-celled  endothelial  sarcoma,  probably  of  the  mem- 
branes of  the  cerebellum. 

The  soft  fibromata  of  the  skin:  These  tumors  presented  the  usual 
appearances  of  such  growths.  They  consisted  of  delicately  fibrillated 
connective  tissue  richly  nucleated  with  small,  elongated,  or  rod-like 
nuclei,  frequently  curved  or  twisted.  In  all  parts  of  the  sections 
brightly  stained  round  nuclei  were  seen,  which  were  transversely  cut 
sections  of  the  rod-like  form.  In  certain  places  groups  of  round 
nuclei  were  found,  probably  centers  of  growth.  In  some  parts  of  the 
sections  nuclei  of  both  forms  were  very  numerous,  giving  the  tissue  a 
general  resemblance  to  spir.dle-celled  sarcoma;  but  careful  examination 
would  show  that  in  the  fibroma  the  nuclei  are  among  the  fibers  and  not 
"within  spindle  cells,  and  that  in  the  fibrous  tumor  the  tissue  is  more 
mature  and  dense  than  in  fibro-sarcoma.     For  comparison  with  the 


GOVERNMENT    HOSPITAL    FOR    THE    INSANE.  53 

brain  tumor  I  have  drawn  two  fields  from  the  fibromata  one  showing 
a  richly  nucleated  field,  the  other  the  more  typical  appearance,  of  the 
growth. 

The  bloodvessels  in  the  denser  and  older  portions  of  the  tumors  were 
not  numerous,  and  many  presented  the  appearance  of  mere  channels 
in  the  tissue  lined  with  endothelium.  In  the  more  cellular  part  of  the 
tissue  many  new-formed  blood  vessels  were  found  in  all  stages,  from 
capillaries  to  fully  developed  arteries  and  veins.  On  the  borders  of 
the  tumors  adjoining  the  true  skin  the  deeper  parts  of  coil  glands, 
sebaceous  glands,  and  deep-hair  follicles  were  included  in  the  new 
tissue.  Peripheral  nerve  trunks  were  found  occasionally  within  the 
tumor  tissue,  and  though  there  was  undoubtedly  some  increase  of  the 
connective  tissue  of  the  nerves,  especially  of  the  epineurium,  there 
was  no  other  evidence  of  connective  tissue  of  the  nerves  entering  into 
the  formation  of  the  growths. 

Brain:  The  pia  mater  was  thickened;  the  blood  vessels  of  the  brain 
were  tortuous  and  lay  in  wide  perivascular  spaces  with  much  altered 
blood  pigment  around  them.  The  nerve  cells  were  granular  and  exces- 
sively pigmented;  perivascular  and  pericellular  spaces  enlarged.  The 
cerebellum,  pons,  and  medulla  were  not  examined. 

Lungs:  The  sections  from  the  apices  showed  chronic  tubercular 
deposits  in  the  alveolar  walls  and  around  the  bronchi.  The  tubercular 
nodules  were  surrounded  by  dense  masses  of  round  cells  in  which  were 
many  blood  vessels.  The  central  portions  of  the  nodules  were  com- 
posed of  epithelioid  cells  of  various  sizes  and  shapes  apparently  in  the 
early  stages  of  tissue  formation.  No  vessels  were  found  in  the  central 
cell  masses,  but  degeneration  had  not  taken  place  on  account  of  the 
vascular  supply  to  the  peripheral  parts  of  the  nodule.  Very  few 
giant  cells  were  found.  Some  of  the  alveoli  were  narrowed  by  thick- 
ening of  their  walls  and  contained  a  few  epithelial  cells.  In  the 
hemorrhagic  areas  the  alveoli  contained  blood  and  the  vessels  were 
engorged. 

Spleen:  The  capsule  was  thick,  the  trabecular  prominent.  The  pulp 
showed  great  engorgement,  large  areas  contained  nothing  but  blood. 

Liver:  The  tissues  showed  nothing  abnormal  except  slight  passive 
congestion  and  some  pigmentation  of  the  cells. 

Kidneys:  There  was  a  slight  increase  of  the  connective  tissue, 
mainly  around  the  glomeruli.  The  tissue  contained  more  blood  than 
usual;  the  tubules  were  slightly  dilated;  the  epithelium  granular  and 
somewhat  disintegrated  at  the  inner  margins,  and  the  tubules  con- 
tained granular  matter  probably  derived  from  the  cells. 

The  other  organs  were  not  examined  with  the  microscope,  but  were 
apparently  normal. 

CASE  833. 

ENDOTHELIAL  SARCOMA  OF    DURA  MATER,  ADENOID  CANCER  OF  STOMACH, 
AND   ROUND-CELLED   SARCOMA   OF   TESTICLE. 

J.  D. ;  aged  80;  single;  late  soldier;  nativity,  United  States;  mental 
disease,  senile  dementia;  duration,  over  six  3Tears.  In  this  case  there 
were  no  symptoms  of  brain  tumor.  The  patient  was  much  demented, 
deaf,  and  very  feeble  physically,  but  he  had  no  definite  paralysis.  The 
case  possesses  unusual  interest  on  account  of  the  existence  of  three 
tumors  of  different  kinds,  two  of  them  being  malignant  and  the  other 
at  least  semimalignant. 


54  GOVERNMENT    HOSPITAL    FOR    THE    INSANE. 

Autopsy  twelve  hours  after  death.  Body  emaciated  and  cachectic; 
right  testicle  enlarged  and  indurated. 

( ' I'd  n  nin,. — Antero-posterior  diameter  of  skull,  7$  inches;  transverse, 
5&  inches.  Skull  very  thick  and  dense;  the  greatest  thickness  was  in 
the  frontal  and  oeeipital  regions;  skidl  asymmetrical,  the  right  side 
being  the  larger,  and  the  oeeipital  protuberance  was  very  prominent 
and  was  situated  to  the  left  of  the  median  line.  The  forehead  was 
very  receding;  sutures  partly  obliterated  in  external  table  and  not 
distinguishable  in  the  inner  table;  Pacchionian  depressions  large  and 
deep. 

The  dura  mater  was  somewhat  adherent  to  the  bone;  on  the  leftside 
a  strong  membrane  of  internal  pachymeningitis  covered  the  convexity 
of  the  dura  and  extended  downward  over  the  anterior  and  part  of  the 
middle  cerebral  fossa-;  the  right  side  of  the  dura  was  somewhat  thick- 
ened but  otherwise  normal.  In  the  anterior  portion  of  the  left  middle 
cerebral  fossa  was  a  small  tumor,  firmly  attached  to  the  dura  mater  by 
a  somewhat  constricted  base.  The  tumor  was  about  an  inch  and  a 
quarter  in  its  longest  diameter;  it  was  irregularly  globular  in  shape, 
and  the  surface  was  granular  or  finely  nodular.  The  tumor  encroached 
slightly  upon  the  anterior  extremity  of  the  temporal  lobe  and  had  made 
a  small  depression  therein.  Where  the  growth  came  in  contact  with 
the  brain  the  pia  mater  and  cortex  were  adherent  to  the  surface  of  the 
tumor,  and  the  cortex  was  destroyed  over  an  area. about  three-fourths 
of  an  inch  in  diameter. 

On  removing  the  tumor  with  the  dura  mater  the  bone  was  found  to 
be  somewhat  absorbed  beneath  the  growth.  There  was  no  appearance 
of  intracranial  tension,  and  whatever  symptoms  may  have  been  pro- 
duced by  the  tumor  must  have  been  local. 

Brain:  Weight  of  each  hemisphere,  17£  ounces  (496.12  grams);  cere- 
bellum, pons,  and  medulla,  h\  ounces  (155.92  grams).  The  pia  mater 
showed  marked  oedema  and  some  opacity  over  the  superior  portions  of 
the  convexity  and  the  upper  portion  of  the  median  surfaces.  The 
whole  brain  was  much  atrophied,  but  the  greatest  shrinkage  was  over 
the  superior  portion  of  the  convexity.  The  arteries  at  the  base  were 
very  calcareous  and  much  distorted;  the  posterior  communicating 
arteries  were  large  and  furnished  the  main  blood  supply  to  the  poste- 
rior cerebral  region,  as  the  vertebral  system  of  arteries  was  very  ill 
developed.  The  brain  substance  was  very  soft  and  (edematous;  cortex 
pale  and  yellowish  in  color;  white  matter  dark  or  clay  colored;  some 
of  the  minute  arteries  of  the  brain  were  calcareous.  The  ventricles 
were  dilated;  the  ependyma  smooth;  no  gross  lesions  in  the  interior 
of  the  brain.  The  left  temporal  lobe  showed  a  softened  area  corre- 
sponding to  the  contact  with  the  dural  tumor,  as  above  mentioned. 
The  softened  area  was  not  large,  but  the  cortex  over  it  was  softened 
and  destroyed,  and  the  white  matter  was  slightly  invaded.  Cerebellum, 
pons,  and  medulla  showed  no  gross  lesions. 

Thorax. — Firm  pleuritic  adhesions  on  both  sides. 

Lungs:  Weight  of  right,  35  ounces  (992.25  grams);  left,  26|  ounces 
(758.36  grams).  The  left  lung  showed  great  thickening  of  the  pleura, 
in  some  places  at  least  half  an  inch  in  thickness.  The  lungs  both 
showed  chronic  bronchial  inflammation  and  inhalation  of  the  products 
of  the  same  into  the  air  vesicles  of  the  posterior  portions  of  the  lungs. 
The  right  lung  showed  a  considerable  degree  of  solidification. 


GOVERNMENT    HOSPITAL    FOR    THE    INSANE.  ■)■) 

Heart:  Weight,  9f  ounces  (276.41  grams).  Valves  of  right  side 
normal;  aortic  valves  a  little  thickened;  edges  of  mitral  valve,  slightly 
thickened.  The  coronary  arteries  were  rigid  tubes,  on  accounl  of  <-;ti- 
careous  degeneration.  The  aorta  was  very  atheromatous  and  calcare- 
ous, especially  at  its  lower  part.  Heart  walls  showed  nothing  of 
importance;  cavities  were  full  of  coagulated  blood. 

Abdomen. — The  spleen  weighed  7  ounces  (198.45  grams);  organ  very 
soft,  almost  diffluent;  splenic  artery  very  calcareous. 

Kidneys:  Weight  of  each,  4i  ounces  (127.57  grams).  Capsules 
adherent;  surfaces  irregular  and  granular;  cortex  thin.  In  the  left 
were  several  large  cysts,  and  in  each  were  a  number  of  whitish 
nodules,  some  about  half  an  inch  in  diameter,  which  were  afterwards 
found  to  be  secondary  deposits  of  round-celled  sarcoma.  Theuninary 
bladder  showed  some  hypertrophy,  and  some  enlargement  of  the  mid- 
gle  lobe  of  the  prostate  gland. 

Liver:  Weight,  53f  ounces  (1,523.81  grams).  Capsule  of  right  lobe 
was  thickened  over  the  convexity;  tissue  normal.  Gall-bladder  con- 
tained an  ounce  of  normal  bile. 

Stomach:  At  the  pyloric  end  of  the  organ  were  four  small  polypoid 
growths,  and  at  the  cardiac  end  was  a  large  cancerous  ulceration  which 
extended  to  the  opening  of  the  cesophagus  but  not  beyond  it,  and  was 
about  2  inches  in  diameter.  The  edges  of  the  ulceration  were  thick- 
ened, and  near  the  edges  were  polypoid  protuberances  and  several  small 
nodules  resembling  those  at  the  pyloric  end.  The  mucous  membrane 
over  the  remainder  of  the  organ  was  mammillated  and  covered  with 
thick  tough  mucus. 

The  duodendum  and  other  parts  of  the  intestinal  tract  were  appar- 
ently normal. 

The  pancreas  was  indurated  and  nodular;  pancreatic  artery  very 
calcareous. 

A  large  group  of  lymphatic  glands  which  were  situated  around  the 
cceliac  axis  and  the  superior  mesenteric  artery  were  found  to  be  greatly 
increased  in  size,  soft,  juicy,  and  were  apparently  confluent,  so  that 
individual  glands  could  only  be  seen  around  the  periphery  of  the  mass. 
Enlarged  glands  could  be  traced  downward  along  the  great  vessels,  and 
several  slightly  affected  nodes  were  found  on  the  spermatic  cord.  The 
right  testicle  was  at  least  ten  times  as  large  as  the  normal,  and  weighed 
about  7  ounces.  Incision  showed  that  the  proper  tissue  of  the  gland 
was  replaced  b}^a  soft,  juicy,  pinkish- white  growth  almost  exactly  like 
that  of  the  mass  of  enlarged  abdominal  glands  described  above.  The 
cavity  of  the  tunica  vaginalis  was  partl}x  obliterated  by  adhesions,  but 
contained  a  few  drachms  of  clear  fluid.     The  other  testicle  was  normal. 

MICROSCOPICAL   EXAMINATION. 

The  main  bulk  of  the  brain  tumor  in  this  case  is  made  up  of  slender 
spindle  cells  with  oval  and  elongated  nuclei,  arranged  in  loose  bands 
and  whorls.  The  cells  are  sometimes  closely  packed,  but  as  a  rule  the 
tissue  is  loosety  intermingled  with  a  small  amount  of  delicate  fibrous 
tissue,  in  which  the  principal  blood  vessels  are  found.  In  some  fields 
the  cells  are  nearly  all  arranged  in  the  form  of  whorls  or  cell-nests,  and 
in  the  centers  of  these  "nests"  are  a  few  endothelioid  cells  with  clear 
distinct  cell  bodies  and  conspicuous  nuclei.  A  few  of  the  smallwhorls 
are  hyaline  in  their  centers,  so  that  individual  cells  can  not  be  distin- 


56  GOVERNMENT    HOSPITAL    FOB    THE    INSANE. 

guished.  A  few  hyaline  globes  of  small  size  are  found,  but  this  feature 
is  n<>t  as  conspicuous  as  in  some  similar  tumors.'  Occasionally  fields 
are  found  where  the  groupsof  endothelioid  cells  are  large,  and  the  con- 
nective tissue  and  spindle  cells  around  form  an  alveolar  arrangement 
of  the  tissue  which  much  resembles  cancer.  One  large  and  several 
small  groups  of  such  cells  are  represented  in  the  drawing  of  this  tumor, 
fig".  3.").  Some  fields  are  apparently  made  up  of  endothelial  cells  lying- 
in  a  supporting  tissue  which  seems  to  consist  of  loose  spindle  cells,  or 
connective  ti.-^sue  fibers  with  elongated  nuclei.  The  blood  vessels  are 
not  numerous,  but  are  found  in  both  the  connective  tissue  and  among 
the  cells. 

The  cancerous  growth  in  the  stomach  is  simply  an  adenoid  cancer, 
and  is  represented  in  tig.  30.  The  only  perplexing  feature  in  the  stom- 
ach tumor  is  the  dense  infiltration  of  the  subserous  tissue  opposite  the 
ulceration,  with  round  cells  which  exactly  resemble  those  found  in  the 
mass  of  enlarged  lymphatic  glands  in  the  vicinity.  I  incline  to  think 
that  it  is  sarcomatous  infiltration,  though  it  may  possibly  be  merely 
inflammatory. 

The  tumor  of  the  testicle,  which  was  probably  the  primary  growth, 
and  the  secondary  deposits  in  the  lymphatic  glands  and  kidney,  proved 
to  be  round-celled  sarcoma.  The  seminiferous  tubules  are  widely  sepa- 
rated by  the  growth  of  sarcomatous  tissue;  the  walls  of  the  tubules  are 
thickened  and  converted  into  a  cellular  structure  which  still  shows  faint 
traces  of  concentric  arrangement  of  the  fibers,  and  the  cells  of  the 
tubules  are  in  disorderly  arrangement  and  are  somewhat  degenerated. 
The  secondary  deposits  show  the  same  t}'pe  of  cell  growth;  those  in 
the  kidney  are  highly  interesting,  as  the}'  show  the  renal  tubules  and 
other  structures  widely  separated  by  the  sarcomatous  tissue.  Blood 
vessels  present  imperfect  walls  wrhen  found  in  the  midst  of  the  cellular 
tissue,  but  some  preexisting  vessels  are  found  around  the  borders  of 
the  new  tissue.  Judging  from  the  histological  structure  of  the  three 
primary  tumors,  1  do  not  think  they  bore  any  relation  to  each  other. 
The  tumor  of  the  testicle  was  rapid  in  its  growth,  and  was  probabty  of 
most  recent  development. 

The  nerve  cells  of  the  brain  show  great  degenerative  changes  and 
large  pericellular  spaces.  The  blood  vessels  are  somewhat  tortuous; 
numerous  perivascular  hemorrhages  are  found,  and  pigment  masses 
are  scattered  along  the  walls.  Some  of  the  vessels  show  an  increase  of 
nuclei  along  their  perivascular  spaces,  and  those  in  the  vicinity  of  the 
softening  in  the  temporal  lobe  show  decided  evidences  of  irritation,  and 
cell  proliferation  is  evident  in  the  brain  tissue  adjoining  the  softening. 
Other  parts  of  the  brain  present  nothing  of  additional  interest. 

The  other  organs  show  nothing  of  special  importance  in  addition  to 
the  naked-eye  appearances. 

CASE  539. 
ENDOTHELIAL   SARCOMA   OF   THE    DURA    MATER. 

W.  C:  aged  81;  married;  late  soldier;  nativity,  Ireland.  Mental 
disease,  senile  dementia ;  duration  over  three  years.  This  case  presented 
nothing  of  interest  in  the  clinical  history,  as  the  tumor  found  was  small 
and  gave  rise  to  no  symptoms.  It  was  regarded  as  a  case  of  senile 
dementia,  with  gross  disease  of  the  brain. 


GOVERNMENT    HOSPITAL    FOR    THE    INSANE.  57 

Autopsy  four  hours  after  death.  Body  emaciated;  signs  of  old  skin 
lesions  on  the  legs,  probably  scurvy;  superficial  veins  prominent  every- 
where; dependent  portions  of  body  livid;  skin  yellowish  everywhere. 
The  left  tibia  showed  indications  of  a  badly  united  fracture;  scar  an 
inch  and  a  half  long  on  left  side  of  forehead. 

Cranium. — On  the  left  side  of  the  frontal  bone  was  a  depression 
about  2  inches  in  length  and  half  an  inch  in  width,  corresponding  with 
the  scar  mentioned  above.  The  inner  surface,  at  the  site  of  the  depres- 
sion, was  slightly  raised,  as  if  the  inner  table  had  been  fractured  at  the 
time  of  the  injury,  but  the  signs  of  fracture  had  disappeared.  The 
skull  was  rather  dense,  diploe  scanty;  shape,  symmetrical;  antero- 
posterior diameter,  7f  inches;  transverse,  5f  inches. 

The  dura  mater  adhered  firmly  to  the  bone,  and  over  the  whole  inner 
surface  was  a  thin  rust-colored  false  membrane.  On  the  right  side  of 
the  convexity,  over  the  parietal  lobe,  a  small  tumor  projected  from  the 
inner  surface  of  the  membrane.  The  tumor  was  about  three-eighths 
of  an  inch  in  diameter;  projected  about  three-sixteenths  of  an  inch  from 
the  surface  of  the  dura.  The  growth  was  granular  on  its  surface;  it 
was  firmly  seated  on  the  membrane,  and  section  showed  it  to  be  of  a 
grayish-red  color  and  very  vascular.  The  growth  was  too  small  to 
make  any  depression  in  the  brain,  and  it  could  not  have  produced  any 
symptoms.  It  was,  however,  of  some  histological  interest,  and  for 
this  was  carefully  studied  with  the  microscope. 

Brain:  Weight  of  right  half,  20i  ounces  (581  grams);  left  half,  21 
ounces  (595  grams).  The  pia  mater  showed  patches  of  opacity  over 
the  convexity  and  opaque  lines  along  the  principal  veins.  The  arteries 
at  the  base  were  atheromatous  and  calcareous,  and  were  irregularly 
dilated,  looped,  and  curved.  On  the  right  side  the  posterior  com- 
municating artery  was  larger  than  normal,  and  the  left  was  represented 
by  small  branches  distributed  to  the  crus,  and  did  not  join  the  posterior 
cerebral  artery  as  usual. 

The  convolutions  were  greatly  shrunken  everywhere,  and  the  parts 
of  the  base  were  atrophied.  A  small  cortical  softening  was  found  in 
the  right  superior  temporal  convolution.  The  brain  tissue  was  very 
cedematous,  the  perivascular  spaces  were  enlarged,  and  the  consistence 
of  the  brain  substance  was  reduced.  The  ventricles  were  dilated;  the 
ependyma  was  smooth.  Nothing  abnormal  was  noted  in  the  cerebel- 
lum, pons,  medulla,  and  in  the  cervical  portion  of  the  cord  removed 
with  the  brain. 

Thorax. — The  right  pleural  cavity  contained  36  ounces  of  fluid.  The 
left  side  contained  the  normal  quantity.  Lungs:  Weight  of  right,  16i 
ounces  (167.77  grams);  left,  18i  ounces  (521.47  grams).  The  left  lung 
was  slightly  adherent,  showed  some  emphysema  of  anterior  margins, 
and  the  bronchi  showed  evidences  of  chronic  bronchitis.  The  right 
lung  showed  chronic  thickening  of  the  pleura,  circumscribed  adhe- 
sions, emphysema,  chronic  bronchial  inflammation,  and  the  lower  lobe 
and  a  portion  of  the  middle  lobe  were  collapsed  and  of  a  gray  slate 
color. 

Heart:  The  pericardial  fluid  was  slighth^  increased;  heart  distended 
with  fluid  blood.  Pulmonary  valves  normal;  tricuspid  valve  slightly 
thickened  at  its  free  margins,  and  the  orifice  admitted  five  fingers  side 
by  side.  The  aortic  valves  were  slightly  thickened,  some  elevations 
were  seen  along  the  line  of  contact,  and  there  were  some  calcareous 
patches  between  the  layers  of  the  valves.     The  mitral  valve  was  much 


58  GOVERNMENT    HOSPITAL    FOR    THE    INSANE. 

thickened,  its  chordae  tendinse  shortened  and  thickened,  and  the  apices 
of  the  muscular  papillae  were  fibrous.  The  valve  had  some  small 
chronic  vegetations  along  the  line  of  contact.  The  auricles  were 
greatly  dilated.  Both  ventricles  showed  slight  hypertrophy  and  some 
dilatation.  The  weight  when  emptied  of  blood  was  l.H  ounces  (439.42 
grams). 

Abdomen,. — Spleen:  Weight,  Gi  ounces  (177.18  grams).  Capsule 
thickened  in- patches;  pulp  tinner  than  normal. 

Kidneys:  Weight  of  right,  5  ounces  (141.75  grams);  left,  6|  ounces 
(191.36  grams).  The  right  kidney  was  movable  and  was  situated 
below  and  to  the  left  of  its  normal  position.  The  shape  of  the  organ 
was  abnormal,  the  hilus  was  directed  forward,  and  the  artery  entered 
the  substance;  of  the  organ  outside  the  hilus.  The  left  kidney  was  in 
its  normal  position;  the  capsule  was  adherent;  surface  granular;  cor- 
tex thin,  irregular  on  the  surface,  and  a  number  of  cysts  showed  on 
the  removal  of  the  capsule.  The  pyramids  were  somewhat  atrophied 
and  the  pelvic  fat  was  increased.  The  right  kidney  was  less  altered 
by  disease  than  the  left.  The  urinary  bladder  was  normal,  except 
some  hypertrophy  of  the  middle  lobe  of  the  prostate  gland. 

Liver:  Weight,  58|-  ounces  (1,516.72  grams).  The  surface  was  gran- 
ular, borders  irregular,  and  a  few  yellowish-white  patches  of  small  size 
were  seen  on  the  surface.  On  incision  the  cut  surface  showed  the  typ- 
ical appearances  of  common  cirrhosis.  The  gall  ducts  throughout  the 
organ  were  dilated  and  at  the  lower  end  of  the  common  duet  a  large 
impacted  caculus  was  found.  The  cystic  bile  duct  and  the  bladder  were 
dilated  and  the  latter  contained  pale,  wateiy  bile  and  thirteen  small 
calculi. 

The  pancreas,  stomach,  and  intestines  seemed  normal. 

MICROSCOPICAL   EXAMINATION. 

The  tumor  consists  of  spindle  cells,  large  endothelioid  cells  arranged 
in  groups,  numerous  blood  vessels,  and  some  connective  tissue.  The 
cells  are  somewhat  difficult  to  describe;  man}^  spindle  cells  are  found 
everywhere  in  the  sections,  arranged  in  bands,  around  the  vessels,  and 
in  the  connective  tissue.  Transition  shapes  between  the  large  endo- 
thelioid cells  and  the  spindle  cells  are  seen  in  certain  places  in  the  sec- 
tions. The  endothelioid  cells  are  rather  more  important  constituents 
of  the  growth  than  the  spindle  cells.  They  are  found  in  large  groups, 
separated  in  places  bj  open  linear  spaces  which  divide  the  cells  into 
irregular  masses  and  rows  which  much  resemble  columns  of  liver  cells. 
Ko  explanation  of  this  peculiar  arrangement  was  arrived  at. 

The  groups  of  endothelioid  cells  are  separated  more  or  less  perfectly 
by  loose  bands  of  spindle  cells  with  some  connective  tissue  running 
with  them,  and  by  areas  containing  many  large  blood  vessels  with  la}T- 
ers  of  spindle  cells  around  them. 

The  blood  vessels  constitute  a  very  important  part  of  the  tumor; 
they  are  very  large  and  numerous  and  uniformly  filled  with  blood. 
Their  walls  are  made  up  of  an  endothelial  coat  reinforced  by  a  variable 
amount  of  connective  tissue  and  spindle  cells.  Sometimes  many  layers 
of  spindle  cells  are  seen  around  a  vessel,  and  sometimes  the  wall  seems 
to  be  mainly  fibrous  tissue.  I  have  not  found  any  muscular  fibers  in 
the  vessel  walls. 

The  vessels  are  mainly  in  the  loose  connective  tissue  between  the 
groups  of  cells,  though  a  few  are  found  in  the  fasciculi  of  spindle  cells; 


GOVERNMENT    HOSPITAL    FOR    THE    INSANE.  59 

none  are  found  in  the  dense  masses  of  endothelioid  cells.  The  vessels 
are  of  course  of  new  formation,  though  their  mode  of  origin  is  not 
clearly  established. 

The  diagnosis  is  endothelial  sarcoma,  originating  probably  in  the 
endothelium  of  the  lymph  spaces  of  the  dura  mater,  or  from  the  cells 
of  its  inner  lining. 

The  brain  cells  show  advanced  degenerative  changes;  the  cell  bodies 
are  granular  and  yellow  and  many  are  disintegrated  at  their  margins. 
The  vessels  are  tortuous,  and  a  few  hemorrhages,  and  much  pigment  is 
found  in  the  perivascular  spaces.  The  cerebellum,  pons,  and  medulla 
show  some  vascular  changes  and  some  cell  degeneration. 

The  liver  shows  the  microscopical  appearances  of  common  cirrhosis. 

The  kidneys  show  some  increase  of  the  intertubular  tissue.  Other 
organs  not  examined. 

CASE  278. 

SPINDLE-CELLED    SARCOMA    OF   THE   DURA   MATER. 

W.F. ;  aged  67;  chiropodist;  nativity,  United  States;  mental  disease, 
senile  dementia;  duration  over  one  year.  In  this  case  the  tumor  was 
small  and  had  produced  no  symptoms.  Owing  to  the  atrophy  of  the 
brain,  no  depression  had  been  made  in  the  surface.  The  cause  of  death 
was  probably  atheromatous  softenings  of  the  brain. 

Autopsy  twentjr-four  hours  after  death.     Body  well  nourished. 

Cranium. — Antero-posterior  diameter  of  the  skull,  7-J  inches;  trans- 
verse, 5$  inches.  Skull  bone  normal.  Dura  mater  unusually  adherent 
to  the  bone  along  the  borders  of  the  superior  longitudinal  sinus.  A 
small  tumor  was  found  on  the  inner  surface  of  the  dura  over  the  pos- 
terior portion  of  the  right  superior  frontal  convolution.  No  depres- 
sion was  made  in  the  cortex,  as  the  tumor  was  small  and  did  not 
project  over  one-fourth  of  an  inch  from  the  surface  of  the  dura. 

Brain:  Weight,  42  ounces  (1,190.70  grams).  The  pia  mater  over 
the  left  temporal  lobe  was  adherent  to  the  dura  over  a  region  corre- 
sponding to  a  large  softening  involving  almost  the  whole  lobe.  Another 
large  softened  area  involved  the  lower  part  of  the  left  occipital  lobe. 
The  large  softenings  extended  through  the  white  matter  to  the  epen- 
djana  of  the  ventricles  and  several  small  areas  were  found  in  the  basal 
ganglia.  On  the  right  side  no  softenings  were  found,  but  the  general 
consistence  was  reduced.  The  arteries  were  very  atheromatous,  in 
some  places  nearly  obstructed.  The  other  organs  showed  nothing  of 
importance. 

MICROSCOPICAL   EXAMINATION. 

The  microscope  showed  the  growth  to  be  a  spindle-celled  endothelial 
sarcoma  of  the  dura  mater,  in  structure  quite  similar  to  that  in  case  76. 
The  predominating  types  of  cells  were  spindle-shaped  with  oval  nuclei 
and  sharply  attenuated  ends  and  small  groups  of  round  endothelioid 
cells  which  had  not  yet  assumed  the  spindle  form.  On  transverse 
section  the  spindle  cells  appeared  as  small  rounded  elements  with  scantj^ 
protoplasm  lying  among  the  longitudinal  bands.  The  transverse  sec- 
tions were  extremely  hard  to  differentiate  into  individual  cells,  and 
the  spindles  could  be  recognized  mainly  b}T  the  shape  and  direction 
of  the  nuclei.  The  cell  masses  in  general  showed  slight  tendency  to 
form  concentrically  arranged  groups  and  only  a  few  hyaline  spherules 
of  small  size  were  found. 


60  GOVERNMENT    HOSPITAL    FOR   THE    INSANE. 

Irregular  delicate  bands  of  connective  tissue  intersected  the  cell 
structure.  Those  usually  carried  the  largest  blood  vessels,  often  with 
thick  fibrous  walls:  smaller  vessels  with  sometimes  fibrous  walls  and 
sometimes  -as  mere  endothelial  channels  were  found  among  the  cells. 

The  brain  tissue  showed  do  effects  which  could  be  attributed  to  the 
tumor,  and  the  microscopic  examination  of  other  organs  was  not  con- 
sidered important. 

SEEIES  II.  GLIOMATA, 

Five  of  the  tumors  studied  were  gliomata  originating  in  the  brain 
substance.  Of  these,  three  were  much  degenerated,  but  in  parts  the 
tissue  was  sufficiently  preserved  for  diagnosis.  The  tumor  represented 
by  fig.  53,  case  820,  should  probably  be  classed  with  the  gliomas,  but 
on  account  of  its  cellular  structure  it  has  been  put  down  as  glio-sarcoma, 
and  will  be  described  later  on. 

The  gliomata  are  tumors  originating  from  the  glia",  or  supporting 
tissue  of  the  central  nervous  system,  and  possibly  in  some  nervous 
structures  elsewhere.  The  glia  cells  and  fibrils  are  now  believed  to  be 
of  ectodermic  origin,  and  therefore  must  be  closely  related  both  to  the 
nerve  cells  and  the  surface  epithelium.  This  view  makes  it  clear  how 
we  may  have  the  varieties  of  the  growth  such  as  ganglionic,  ependy- 
mal,  astrocytic,  and  fibrillary  gliomata.  All  of  the  writer's  cases  were 
of  the  astrocyte  type,  though  comnionly  presenting  great  variety  and 
complexity'  of  structure.  In  all  gliomata  the  essential  structure  is 
composed  of  cells  of  ectodermic  origin  and  fibrils  supposed  to  be 
derived  from  them,  though  in  some  tumors  the  fibrillated  structure 
seems  to  be  distinct  from  the  cell  elements,  and  it  may  be  differentially 
stained.  In  ordinary  staining,  and  especially  if  the  tissue  has  not  been 
well  preserved,  it  is  extremely  difficult  to  determine  the  origin  and 
nature  of  the  fibrillary  intercellular  substance. 

In  addition  to  the  ectodermic  elements,  the  gliomata  are  richly  sup- 
plied with  blood  vessels  and  their  accompanying  fibrous  tissue,  both 
of  mesodermic  origin.  On  this  account  there  seems  to  be  good  reason 
for  regarding  the  gliomata  as  compound  tissue  tumors,  indeed  closely 
allied  to  the  carcinomata  in  histogenesis.  It  must  be  also  remembered 
that  glioma  is  closely  related  to  the  several  forms  of  gliosis,  and  to 
embryonic  errors  of  development. 

In  view  of  the  recent  observations  as  to  the  histogenesis  of  the 
neuroglia,  the  presence  of  an  unusual  number  of  round  cells,  if  known 
to  be  of  mesodermic  origin,  would  warrant  the  continued  use  of  the 
term  glio-sarcoma,  used  for  a  combination  tumor,  and  not  as  a  desig- 
nation for  a  variety  of  sarcoma  or  a  transition  form  of  growth. 

In  the  descriptions  of  some  of  the  gliomata  studied  some  time  ago 
the  views  as  to  the  origin  and  nature  of  the  neuroglia  then  held  were 
accepted.  It  has  not  been  considered  as  essential  to  change  this,  as 
the  exact  relation  of  the  elements  of  the  supporting  and  nutrient  tis- 
sues of  the  nervous  system  is  not  yet  settled. 

In  the  drawings  from  these  growths  fields  showing  the  general 
structure  were  selected,  though  in  all  great  variations  of  structure 
were  found  in  different  parts,  necessitating  in  some  cases  several  draw- 
ings from  the  same  tumor. 

An  interesting  feature  in  one  case  was  the  presence  of  a  small  field 
of  cancer-like  alveoli  containing  cells  indistinguishable  from  those  of 
ordinary  cancer.     The  presence  of  epithelial  cells  in  a  tumor  of  ecto- 


GOVERNMENT    HOSPITAL    FOE    THE    INSANE.  61 

dermic  origin  would  not  be  remarkable,  but  the  origin  of  these  cells 
was  not  determined.     (Sec  fig.  4<S,  and  note  to  case  1426.) 

The  gliomata  have  been  illustrated  by  four  plates  and  eleven  draw- 
ings, showing  the  structure  as  it  appears  under  ordinary  amplifications 
and  some  of  the  developmental  and  degenerative  modifications  of  the 
gliomatous  tissue. 

CASE  601. 

GLIOMA    OF   THE    RIGHT    FRONTAL    LOBE. 

J.  S. ;  aged  42;  single;  soldier;  nativity,  United  States.  Mental 
disease,  dementia;  duration,  seven  months.  The  symptoms  in  this 
case  were  characteristic  of  brain  tumor,  the  dementia  was  well 
advanced,  and  there  was  marked  paralysis  of  left  arm  and  leg. 

Autopsy  twenty-six  hours  after  death.  Body  well  nourished;  bed 
sores  over  sacrum  and  both  trochanters. 

Cranium. — Antero-posterior  diameter  of  skull,  7f  inches;  transverse, 
6f  inches;  skull  thin;  sutures  indistinct;  shape  slightly  asymmetrical. 
Dura  mater  somewhat  adherent  to  the  bone  and  unusually  tense  over 
the  right  side.  On  reflecting  the  dura  slight  inflammatory  adhesions 
to  the  pia  mater  and  cortex  were  noted  anterior  to  the  upper  end  of 
the  fissure  of  Rolando,  the  site  of  the  brain  tumor  to  be  described. 

Brain:  Weight,  48  ounces  (1,360.80  grams).  The  right  hemisphere 
was  considerably  enlarged  anteriorly  and  pressed  toward  the  left,  so 
that  the  falx  had  made  a  deep  impression  on  the  median  surface.  The 
convolutions  were  flattened  over  the  right  frontal  lobe,  the  surface 
was  dry,  and  the  superficial  vessels  were  congested  over  the  situation 
of  the  tumor. 

Incision  showed  a  large  growth  situated  in  the  brain  at  the  posterior 
ends  of  the  right  first  and  second  frontal  convolutions.  It  was  globu- 
lar in  shape,  about  2i  inches  in  average  diameter,  and  apparently  had 
developed  in  the  white  matter,  the  cortex  not  being  involved,  except 
by  the  inflammatory  congestion  and  adhesions  above  noted.  Section 
showed  that  the  growth  extended  into  the  white  matter  of  the  first 
frontal  convolution,  paracentral  lobule,  second  frontal,  and  ascending 
frontal  convolutions,  and  had  pressed  backward  upon  the  central  fissure 
and  flattened  the  ascending  parietal  g3Trus. 

The  tumor  was  quite  soft,  reddish  gv&y  in  color,  vascular,  and  the 
boundaries  were  very  distinct.  The  white  matter  in  the  immediate 
vicinity  of  the  tumor  was  appreciably  indurated;  the  cortex  over  it 
was  softened  and  reddened.  A  small  cyst  was  situated  beneath  the 
tumor,  between  it  and  the  roof  of  the  ventricle;  it  was  separated  from 
both  by  a  layer  of  white  matter.  The  cyst  contained  clear  watery 
fluid  and  was  apparently  independent  of  either  tumor  or  ventricle. 

The  tumor,  on  account  of  its  gross  appearances,  was  thought  to  be 
some  form  of  sarcoma,  but  subsequent  microscopical  examination 
showed  the  structure  of  unusually  vascular  glioma.  Other  portions 
of  the  brain  showed  no  gross  lesions  and  there  were  no  secondary 
deposits. 

Thorax. — Chronic  pleuritic  adhesions  on  both  sides. 

Lungs:  Weight  of  right,  25^  ounces  (731.92  grams);  left,  20  ounces 
(567  grams).  Extensive  gangrene  of  right  lung,  with  somewhat  less 
involvement  of  the  left. 

Heart:  Weight,  Hi  ounces  (318.93  grams).  Slight  chronic  disease 
of  mitral  valve. 


62  GOVERNMENT    HOSPITAL    FOR    THE    INSANE. 

Abdomen. — Spleen:  Weight,  6|  ounces  (191.36  grams).  Pulp  dark 
and  soft. 

Kidneys:  Weight  of,  Gi  ounces  (184.72  grams);  right,  4$  ounces 
(121.57  grams).  Sonic  engorgement  of  the  .surface  veins  and  slight 
swelling  of  the  cortex. 

Liver:  Weight,  4So  ounces  (1,374.97  grams).  Slight  passive  conges- 
tion and  some  bile-staining  of  the  tissue. 

Other  organs  were  apparently  normal. 

MICROSCOPICAL    EXAMINATION. 

The  tumor  was  found  to  be  a  glioma  of  very  complex  structure. 
The  cells  were  multiform,  but  many  were  spindle-shaped  and  round 
like  those  of  sarcoma.  The  round  cells  were  mainly  small,  and  were 
most  numerous  in  the  vicinity  of  the  blood  vessels,  some  of  which 
were  surrounded  by  dense  groups  of  these  cells. 

The  spindle  cells  were  found  mainly  in  bands  running  in  every 
direction,  and  astrocytes  and  large  round  cells  lay  in  groups  among 
them.  Some  fields  seemed  to  be  mad*1  up  of  large,  irregularly  shaped, 
spindle  cells,  large  and  small  round  cells,  and  scanty  granular  inter- 
cellular substance.  Such  tissue  could  readily  be  mistaken  for  poly- 
morphous-celled sarcoma.  The  intercellular  matrix  in  general 
appeared  granular,  with  a  few  fine  fibers,  processes  of  astrocytes, 
and  spindle  cells,  giving  it  a  faintly  striated  appearance  in  some  places. 

The  blood  vessels  were  large  and  numerous  in  all  parts  of  the 
growth.  They  had  thin,  undeveloped  walls,  and  commonly  were 
accompanied  by  a  little  fibrous  adventitial  tissue.  Occasionally  vessels 
with  fully  developed  walls  were  found,  probably  preexisting  cerebral 
arteries  and  veins,  such  growths  being  alterations  of  the  tissue  rather 
than  substitutions. 

The  peculiar  grouping  of  the  glia  cells  in  the  vicinity  of  some  of  the 
vessels,  such  as  shown  in  tig.  46,  case  1053,  was  sometimes  observed 
in  this  tumor. 

To  assign  tumors  such  as  this  to  their  proper  class  is,  of  course, 
very  difficult,  but  careful  examination  of  the  most  characteristic  parts 
confirmed  the  diagnosis  of  glioma,  probably  primarily  of  the  astrocytic 
type.  The  possible  and  even  probable  correlative  increase  of  the 
mesoblastic  elements  must  be  borne  in  mind,  and  to  call  such  growths 
gliosarcomata,  in  the  sense  of  combination  tumors,  would  not  be 
improper. 

The  brain  tissue  around  the  tumor  showed  some  evidences  of  irri- 
tative overgrowth  of  the  glia  cells,  the  cortex  was  congested,  and  the 
nerve  cells  were  granular  and  crumbled.  Other  organs  showed  no 
important  histological  changes. 

CASE  832. 

GLIOMA    OF    LEFT   TEMPORAL   LOBE. 

A.  E. ;  aged  7-2;  widower;  late  soldier;  nativity,  United  States. 
Mental  disease,  chronic  epileptic  dementia,  duration  unknown.  The 
history  previous  to  his  admission  to  this  hospital  is  very  indefinite. 
He  was  demented  when  admitted,  and  had  been  melancholy  and  threat- 
ened suicide  at  the  Soldiers'  Home.  While  in  the  hospital  he  was 
always  feeble  and  confined  to  bed.     Three  weeks  before  his  death  he 


GOVERNMENT    HOSPITAL    FOR    THE    INSANE.  63 

had  a  severe  convulsion,  with  coma,  lasting-  eighteen  hours.  He 
suffered  from  severe  pain  in  the  lumbar  spine,  which  was  aggravated 
by  moving  him,  and  he  had  partial  paralysis  of  legs.  Four  days  before 
his  death  he  had  an  attack  of  partial  coma,  with  apparent  paralysis  of 
right  arm  and  leg  and  some  impairment  of  reflex  action;  the  mouth 
was  drawn  to  the  left  side;  swallowing  was  difficult;  the  pupils  were 
normal  in  size,  but  moved  slowly.  The  general  paralytic  condition 
continued  to  increase  until  death  occurred. 

Autopsy  seventeen  hours  after  death.  Body  well  nourished;  bed 
sores  over  sacrum. 

Cranium. — Antero-posterior  diameter,  7i  inches;  transverse,  5f 
inches.  Skull  of  the  usual  thickness;  diploe  abundant  and  congested; 
inner  surface  of  frontal  bone  somewhat  nodular;  sutures  partly  obliter- 
ated; arterial  depressions  large  and  deep.  Dura  mater  not  unusually 
adherent  to  the  bone;  falx  fenestrated  in  frontal  portion,  and  the  adhe- 
sions to  the  pia  mater  along  the  edges  of  the  median  surfaces  were 
firmer  than  normal. 

Brain:  Weight  of  right  hemisphere,  23f  ounces  (673.31  grams);  left 
hemisphere,  27  ounces  (765.45  grams);  cerebellum  and  brain  stem,  6f 
ounces  (191.36  grams).  The  convolutions  of  the  left  hemisphere  were 
flattened  against  the  skull  at  the  parietal  and  temporal  regions.  Upper 
portions  of  subdural  space  dry.  Brain  cortex  unusually  dark  in  color. 
A  large,  soft,  hemorrhagic,  and  gelatinoid  growth  occupied  the  lower 
and  posterior  portion  of  the  left  temporal  lobe.  It  was  posterior  to  a 
line  drawn  through  the  retro-central  fissure  and  parallel  with  it.  The 
growth  occupied  almost  the  whole  of  the  white  matter  of  the  temporal 
lobe,  extending  from  the  ventricle  almost  to  the  cortical  substance  of 
the  convex  surface.  The  tumor  did  not  actually  reach*  the  surface  of 
the  brain,  though  a  branch  of  the  posterior  cerebral  artery  seemed  to 
owe  its  firm  adhesions  to  the  pia  mater  to  the  proxirnny  of  the  tumor. 

The  growth  was  extremely  soft,  degenerated,  and  hemorrhagic. 
The  exact  boundaries  could  not  be  determined,  as  the  growth  seemed 
to  gradually  merge  into  the  brain  tissue  around.  The  growth  pre- 
sented a  grayish,  gelatinoid  appearance,  with  some  pigmentation  of 
the  tissues  and  hemorrhage.  The  brain  tissue  generally  was  very 
soft,  oedematous,  and  the  perivascular  spaces  were  enlarged  greatly, 
especially  in  the  lower  and  anterior  portions  of  the  frontal  lobes.  No 
gross  lesions  were  found  in  other  parts  of  the  brain.  Arteries  at  the 
base  showed  patches  of  opacity;  posterior  communicating  arteries 
enlarged,  and  furnished  the  main  blood  supply  to  the  posterior  cere- 
bral region. 

The  ventricles  were  slightly  enlarged,  and  in  the  left  was  found  a 
soft,  yellow  clot,  which  was  supposed  to  be  coagulated  serum,  caused 
by  admixture  of  a  small  quantity  of  blood  which  had  oozed  from  the 
ventricular  surface  of  the  tumor. 

The  cerebellum,  pons,  and  medulla  showed  no  gross  lesions.  .  The 
cortex  of  the  cerebellum  was  very  dark. 

Thorax.— No  pleuritic  adhesions.  Weight  of  right  lung.  28  ounces 
(793.80  grams);  left  lung,  24  ounces  (680.40  grams).  Lungs  oedema- 
tous and  the  posterior  portions  hypostatic;  signs  of  chronic  bronchitis. 

Heart:  Weight,  12-f  ounces  (361.46  grams).  Some  opacity  of  peri- 
cardium over  the  right  auricle  and  ventricle;  valves  of  right  side 
normal;  aortic  valves  thickened  and  calcareous;  mitral  valve  thick- 
ened, contracted,  and  calcareous.     Heart  muscle  flabby  and  relaxed: 


64  GOVERNMENT    HOSPITAL    FOR    THE    INSANE. 

some  dilatation  of  all  the  cavities.  Aorta  atheromatous  and  calcare- 
ous at  its  lower  portion. 

Abdomen. — Spleen  weighed  2£  ounces  (70.87  grams);  pulp  fibrous 
and  pale. 

Kidneys:  Weight  <>f  left,  .V{  ounces  (103. <>l  grams);  right,  5£  ounces 
(155.92  grams).  Capsules  easily  removed;  surfaces  irregular  and  some- 
what granular;  a  few  cysts  in  the  cortex  of  each:  pyramids  slightly 
atrophied;  pelvic  fat  abundant.  The  urinary  bladder  showed  slight 
inflammation  and  contained  some  turbid  urine. 

Liver:  Weight,  53.V  ounces  (1,516.72  grams).  Tissue  a  little  bile- 
stained:  gall-bladder  normal. 

Other  abdominal  organs  normal. 

MICROSCOPICAL    EXAMINATION. 

The  examination  of  the  tumor  growth  was  very  difficult  on  account 
of  the  degenerative  changes,  hemorrhages,  and  coagulations  in  the 
various  parts  of  the  growth.  By  disregarding  all  the  accidental  con- 
ditions and  examining  the  most  solid  portions  of  the  growth  the  diag- 
nosis was  made  of  glioma. 

The  cells  of  the  tumor  proper  are  of  almost  every  conceivable  shape, 
and  they  vary  almost  as  greatly  in  size.  Branched,  spindle,  round, 
oval,  and  almost  every  imaginable  shape  of  cells  are  found  in  the  most 
typical  fields  without  any  definite  arrangement.  Some  of  the  larger 
cells  have  distinct  nuclei  and  cell  bodies,  but  many  of  the  small  forms 
show  no  trace  of  protoplasm  around  the  apparently  naked  nuclei. 
Some  fields  show  the  cell  forms,  such  as  are  represented  in  tig.  -±3, 
some  are  composed  of  short  spindle  cells,  some  are  made  up  of  round 
cells  intermingled  with  spindle  forms,  and  some  fields  show  nothing 
but  round  cells  of  small  size.  The  ground  substance  is  in  some  fields 
relatively  abundant;  in  some  regions  it  is  scanty.  It  is  coarsely 
granular,  and  shows  a  few  coarse  fibers  in  some  regions.  It  much 
resembles  the  supporting  tissue  of  the  gray  matter  of  the  brain. 
Large  areas  show  nothing  but  granular  material,  the  result  of  degen- 
eration, while  other  regions  are  made  up  of  red  and  white  blood  cells 
and  fibrin. 

In  some  parts  of  the  tumor  blood  vessels  are  very  numerous,  and  are 
large,  tortuous,  and  looped.  They  sometimes  have  very  thick  fibrous 
walls,  which  are  partly  converted  into  hyaline  material.  Frequently 
large  areas  of  coarse  cellular  tissue,  consisting  of  cells  resembling  the 
tumor  elements,  and  loose  fibrous,  tissue  are  seen  to  surround  one  or 
more  vessels,  making  a  kind  of  island  in  midst  of  fields  of  cells.  The 
cells  and  fibrous  tissue  in  these  vascular  islands  are  often  well  pre- 
served and  distinct,  while  the  surrounding  cellular  tissue  is  much 
degenerated.  Vessels  with  a  small  quantity  of  fibrous  tissue  are  also 
found  in  the  midst  of  the  fields  of  tumor  cells. 

In  the  vicinity  of  the  tumor  limits  the  brain  tissue  shows  spider  cells 
and  swollen  neuroglia  nuclei;  but  these  elements  do  not  seem  to  enter 
directly  into  the  tumor  growth. 

The  nerve  cells  in  the  brain  generally  show  granular  pigmentary 
degeneration;  the  pericellular  spaces  are  greatly  enlarged.  The  ves- 
sels show  some  distortion  and  a  marked  increase  of  nuclei  in  their 
perivascular  spaces,  especially  in  the  vicinity  of  the  tumor.  The 
nerve  cells  of  cerebellum,  medulla,  and  spinal  cord  show  slight  gran- 
ular degeneration. 

The  kidnej"  sections  show  some  increase  of  fibrous  tissue. 


GOVERNMENT    HOSPITAL    FOR    THE    INSANE.  65 

CASE    1053. 
GLIOMA    OF    THE    liRAIN. 

J.  B.;  aged  75;  widower;  painter;  late  soldier;  nativity,  United 
States.     Mental  disease,  senile  dementia;  duration  uncertain. 

The  patient  was  considerably  demented  when  lie,  was  admitted,  so 
that  any  close  stiuty  of  the  subjective  symptoms  was  impossible.  He 
showed  none  of  the  characteristic  symptoms  of  intracranial  growth 
except  the  dementia,  and  tumor  of  the  brain  was  not  suspected. 

Autopsy  four  hours  after  death.  Bod}'  well  nourished  for  the  age 
of  the  patient;  rigor  mortis  present  in  muscles  of  head  and  neck. 

Cranium. — Skull  slightly  thicker  than  usual;  sutures  partly  obliter- 
ated in  inner  table;  the  depressions  for  the  middle  meningeal  artery 
large;  Pacchionian  depressions  normal;  dura  mater  generally  a  little 
thickened  and  adherent  to  the  bone.  Cerebrospinal  fluid  somewhat 
increased. 

Brain:  Weight  of  right  hemisphere,  21£  ounces  (609.52  grams);  left, 
19i  ounces  (552.82  grams);  cerebellum,  pons,  and  medulla.  5f  ounces 
(163.01  grams).  On  removing  the  dura  mater  from  the  convexity  a 
slight  increase  of  intracranial  tension  was  observed  over  the  frontal 
lobes,  especially  the  lower  portions;  vessels  of  the  pia  mater  mod- 
erately full  of  blood.  Convolutions  generally  somewhat  atrophied 
over  the  convexity.  On  separating  the  frontal  lobes  a  tumor  mass 
was  found  in  the  anterior  portion  of  the  corpus  callosum  and  adjoining 
portions  of  the  hemispheres.  Section  showed  that  the  growth  had 
enlarged  the  genu  of  the  corpus  callosum  to  about  twice  its  normal 
thickness,  and  had  extended  laterally  into  the  frontal  lobes,  ending 
indefinitely  in  the  white  matter.  The  greater  portion  of  the  growth 
was  in  the  right  hemisphere,  but  the  exact  size  could  not  be  deter- 
mined, as  the  tumor  tissue  gradually  ended  in  the  surrounding  brain 
substance.  The  tumor  tissue  seemed  to  involve  the  greater  portion  of 
the  white  substance  of  the  right  frontal  lobe  anterior  to  the  ventricle, 
and  to  a  less  degree  the  left  frontal  lobe  was  invaded.  The  growth 
had  just  visibly  encroached  upon  the  lateral  ventricles,  but  had  not 
extended  backward  beyond  the  anterior  portion  of  the  ventricular 
cavities.  Examination  of  the  interior  showed  the  tumor  to  be  soft, 
friable,  and  grayish-white  in  color,  somewhat  mottled  with  hemor- 
rhagic areas.  The  brain  tissue  in  the  vicinity  of  the  tumor  was  very 
soft,  yellowish,  disintegrated,  and  some  of  the  serum  which  tilled  the 
loose  meshes  of  the  broken-down  brain  substance  had  coagulated  into 
soft,  yellow  clots.  The  convolutions  of  the  median  surfaces  over  the 
growth  showed  swelling  and  oedema,  so  that  the  arteries  were  deeply 
embedded  in  the  surface  and  the  two  median  surfaces  were  flattened 
against  each  other  by  mutual  pressure.  The  brain  substance  generally 
was  soft  and  oedematous,  and  both  white  and  gray  matter  had  a  faint 
pinkish  tinge.  No  other  gross  lesions  were  found  in  any  part  of  the 
brain.     Cervical  spinal  cord  removed  with  the  brain  seemed  normal. 

Th orax.—  Chronic  pleuritic  adhesions  on  right  side;  left  side  free. 
Weight  of  left  lung,  18  ounces  (510.30  grams);  right  lung,  24i  ounces 
(694.57).  Anterior  portions  of  both  were  slightly  emphysematous; 
posterior  portions  of  both  lungs  were  hypostatic,  partly  solidified  by 
a  slimy  exudate,  and  over  the  surface  of  the  affected  portion  of  the 

24648—03 5 


66  GOVERNMENT    HOSPITAL    FOE    THE    INSANE. 

right  were  some  subpleural  ecchyruoses  and  a  Layer  of  fibrinous  exu- 
date. 

Heart:  Weight,  13£  ounces  (382.72  grams).  Superficial  arteries 
were  opaque  in  patches  and  their  walls  were  tortuous.  Pulmonary 
valves  normal:  tricuspid  valve  slightly  thickened  at  its  edges  and  its 
orifice  admitted  four  fingers;  the  aortic  valves  were  slightly  thickened 
and  showed  some  old  vegetations  and  calcareous  deposits;  mitral  valve 
thickened  at  its  edges  and  somewhat  contracted.  The  auricles  were 
moderately  dilated,  and  the  right  ventricle  showed  some  hypertrophy. 
Arch  of  the  aorta  slightly  dilated  and  atheromatous. 

Abdomen. — The  spleen  weighed  If  ounces  (-49.61  grams);  capsule 
wrinkled;  pulp  tough  and  fibrous. 

Kidneys:  Weight  of  each,  4£  ounces  (120. 48 grams);  capsules  slightly 
adherent  to  cortex:  surface  faintly  granular  and  showed  a  few  small 
cysts:  both  pyramids  and  cortical  substance  somewhat  atrophied.  The 
urinary  bladder  was  slightly  hypertrophied  and  there  was  some  enlarge- 
ment of  the  middle  lobe  of  the  prostate. 

Liver:  Weight,  50  ounces  (1,417.50  grams).  The  tissue  showed 
slight  passive  congestion:  upper  surface  of  right  lobe  was  opaque  in 
patches.     Gall-bladder  contained  .about  an  ounce  of  thick  black  bile. 

Intestines:  The  large  bowel  contained  hard  masses  of  fasces;  small 
intestine  normal;  other  abdominal  organs  were  normal. 

MICROSCOPICAL    EXAMINATION. 

Tumor  and  brain  tissue:  The  arteries  within  the  tumor  were  enor- 
mously thickened:  the  veins  to  a  less  degree.  In  most  cases  the  vessel 
walls  seemed  to  consist  mainly  of  fibrous  tissue  with  a  few  nuclei,  but 
some  appeared  to  have  been  converted  into  hyaline  material;  sonic  of 
the  arteries  were  totally  obliterated  by  the  growth  of  fibrous  tissue. 
The  vessels  as  a  rule  were  tilled  with  blood:  some  contained  thrombi. 
There  were  many  areas  of  hemorrhage  and  coagulated  fibrin  among  the 
cells.  The  tumor  tissue  itself  was  very  difficult  to  study.  It  seemed 
to  consist  of  a  dense  mesh-work  of  rather  coarse  fibers  running  in  every 
direction,  and  in  the  meshes  of  this  fibrous  tissue  lav  the  cellular 
elements.  The  cells  were  of  every  conceivable  shape,  but  the  majority 
seemed  to  be  stellate  or  branched;  there  were  also  small  round  cells, 
large  round  cells,  pyriform,  spindle,  and  other  shapes  without  apparent 
branches.  On  careful  examination  it  seemed  that  much  of  the  fibrous 
interc  dlular  substance  was  made  up  of  the  branches  of  the  stellate 
cells,  but  this  could  not  be  determined  in  the  hardened  tissue.  In 
some  fields  the  tissue  was  very  dense,  and  the  cells  were  of  uniform 
size  and  seemed  to  be  nearly  all  branched  cells  of  various  shapes;  in 
other  fields  the  cell  elements  were  much  larger,  of  unequal  size,  and  of 
every  possible  shape;  in  other  areas  where  the  tissue  seemed  very  loose 
and  degenerated  the  most  of  the  cells  were  very  large,  round,  and 
granular,  much  resembling  the  large  granular  cells  found  in  the  vicinity 
of  cerebral  abscesses.  Fields  showing  these  varieties  of  cells  have 
been  carefully  drawn  by  the  aid  of  the  camera  lucida,  and  are  intro- 
duced to  facilitate  description  (figs.  44  and  4.")). 

The  tumor  tissue  was  found  to  extend  far  into  the  brain  substance, 
and  the  cell  elements  gradually  became  smaller  and  resembled  more 
and  more  the  ordinary  branched  neuroglia  cells.  These  cells  were  very 
numerous  in  the  brain  substance  in  the  vicinitv  of  the  tumor  tissue, 


GOVERNMENT    HOSPITAL    FOE    THE    INSANE.  67 

but  were  conspicuous  by  their  size  and  numbers  throughout  the  frontal 
lobes.  This  relation  between  the  growth  of  the  neuroglia  cells  and  the 
development  of  the  tumor  shows  clearly  that  we  have  under  considera- 
tion a  neoplasm  derived  from  the  neuroglia,  a  glioma.  The  naked-eye 
appearances  and  other  characteristics  of  the  growth  agree  with  this 
diagnosis.  The  gliomata  vary  greatly7  in  their  histological  details; 
some  are  richly  cellular  and  approach  the  sarcomata  in  structure; 
others  consist  to  great  extent  of  fibrous  tissue  and  are  nearer  the 
fibromata;  but  this  one  is  undoubtedly  a  true  glioma  derived  from  the 
branched  neuroglia  cells. 

A  curious  feature  was  sometimes  observed  in  the  more  degenerated 
portions  of  the  growth.  A  vessel  would  be  seen  surrounded  by  a  dense 
cluster  of  the  glioma  cells  of  every  size  and  shape,  suggesting  the 
grouping  of  spider  cells  in  the  vicinity  of  bloodvessels  in  general 
paralysis  and  other  conditions  of  neuroglia  proliferation.  The  thick- 
ening of  the  blood-vessel  walls  was  probably  clue  to  the  same  cause  as 
the  connective-tissue  overgrowth  which  produced  the  tumor,  as  the 
small  vessels  elsewhere  were  normal  (fig.  46). 

The  tissue  of  other  parts  of  the  brain  showed  some  increase  in  the 
size  and  number  of  the  neuroglia  cells,  but  no  secondary  tumor  depos- 
its. The  nerve  cells  were  in  various  stages  of  granular  degeneration 
throughout  the  brain.  The  cerebellum,  pons,  and  medulla  showed 
nothing  remarkable.     The  spinal  cord  seemed  normal. 

The  other  organs  showed  nothing  of  importance  in  addition  to  the 
naked-e\re  diagnosis. 

CASE    1426. 

GLIOMA    OF    BRAIN    INVOLVING   THE    LEFT   FRONTAL   LOBE. 

W.  C.  G. ;  age,  45;  male;  widower;  sailor;  nativity,  Pennsylvania; 
mental  disease,  chronic  dementia  from  tumor  of  the  brain. 

In  this  case  the  dementia  was  too  extreme  to  obtain  subjective 
symptoms.  He  had  many  of  the  objective  signs  of  organic  disease  of 
brain,  but  tumor  was  not  diagnosticated.  The  usual  symptoms  of 
brain  tumor  observed  were  paralysis  of  the  right  side  extending  to  the 
tongue  and  pharynx,  convulsive  seizures,  and  the  extreme  dementia. 
Delusions,  if  present,  were  obscured  by  the  mental  failure.  Death 
occurred  in  a  convulsive  attack  of  epileptiform  character. 

Autopsy  eight  hours  after  death.  Body  fairly  well  nourished:  s-ome 
lividity  of  dependent  parts  of  body,  head,  and  neck. 

Cranium.  —  Skull  symmetrical;  antero-posterior  diameter,  7  inches: 
transverse,  5f  inches.  The  dura  mater  was  not  adherent  to  the  bone; 
the  membrane  was  tightly  stretched  over  the  brain,  and  the  subdural 
space  was  dry  and  the  surfaces  were  sticky;  no  adhesions  to  the  brain 
were  noted. 

Brain:  Weight  of  right  hemisphere,  540  grams;  left  hemisphere, 
640  grams;  cerebellum,  pons,  and  medulla,  160  grams.  The  convolu- 
tions were  greatly  flattened  against  the  dura  mater,  especially  over  the 
left  side,  and  the  left  frontal  portion  was  pressed  over  against  the  falx. 
making  a  deep  impression  of  the  latter  against  the  median  surface. 
Examination  showed  a  large  growth  situated  in  the  left  frontal  lobe, 
evident  by  increase  of  the  size  of  this  part  and  by  enlargement  of  the 
small  pial  vessels  over  it,  though  it  was  situated  beneath  the  cortex 
and  had  the  same  feel  as  the  normal  brain  on  palpation.     Incision 


68  GOVEBNMENT    HOSPITAL    FOR    THE    INSANE. 

showed  a  large,  .soft,  grayish-red  tumor  muss  in  the  frontal  lobe  ante- 
rior to  the  line  of  the  preeentral  fissure.  Both  central  convolutions 
were  strongly  pressed  backward,  the  middle  and  inferior  frontal  con- 
volutions were  pressed  downward  and  outward,  and  the  first  frontal 
was  almost  destroyed  by  the  encroachment  of  the  growth. 

Incision  of  the  tumor  about  the  middle  showed  that  the  growth  was 
probably  a  glioma  or  glio-sarcoma,  originating  from  the  brain  itself; 
it  had  no  definite  boundaries,  seeming  to  end  gradually  in  the  normal 
brain  surrounding  it.  The  central  portions  were  considerably  degen- 
erated and  cystic,  the  peripheral  parts  more  firm  and  redder  from 
greater  vascularity.  No  portion  of  the  new  growth  seemed  to  actually 
reach  the  pia  mater,  though  the  cortex  of  part  of  the  first  frontal  con- 
volution was  extremely  thin.  The  growth  readied  the  roof  of  the 
lateral  ventricle  and  extended  slightly  into  the  corpus  callosum.  The 
extreme  diameters  of  the  growth  were  probably  2  inches  antero-pos- 
teriorly  and  about  If  inches  in  transverse  diameter.  In  the  vicinity 
of  the  tumor  the  brain  tissue  was,  as  is  usually  the  case,  abnormally 
soft;  in  other  parts  the  brain  substance  was  (edematous,  but  no  gross 
lesions  were  found.     The  arteries  were  normal  to  the  unaided  eye. 

Thorax. — Lungs  were  cedematous  and  congested;  bronchi  filled  with 
frothy  mucopurulent  secretion.  Weight  of  right,  490  grams;  left, 
550  grams. 

Heart:  Weight,  340  grams.  Valves  of  right  side  normal  except 
some  enlargement  of  the  tricuspid  orifice.  The  left  valves  were  not 
diseased,  but  the  mitral  orifice  was  slightly  enlarged;  aorta  normal. 

Abdomen. — The  spleen  weighed  390  grams;  capsule  adherent  to  sur- 
rounding parts;  parenchyma  soft  and  dark. 

Kidneys:  Weight  of  right,  160  grams;  left,  140  grams.  Some 
adhesion  of  the  capsules,  and  the  surfaces  were  granular  and  contained 
a  few  cysts.  The  cortex  was  about  the  usual  thickness.  The  urinary 
bladder  was  normal. 

Liver:  Weight,  1 94  grams.  The  organ  contained  a  little  more  blood 
than  usual,  but  was  otherwise  normal.  The  gall-bladder  contained  a 
large  number  of  calculi. 

Stomach  and  intestines  normal. 

MICROSCOPICAL   EXAMINATION. 

The  tumor  was  found  to  be  made  up  of  cells  of  almost  every  con- 
ceivable size  and  shape,  lying  in  a  matrix  apparently  composed  of 
delicate  fibrils.  The  predominating  kind  of  cells  was  the  branched, 
or  asteroid  elements  which  are  usual  in  tumors  of  this  type.  They 
varied  greatly  in  size  and  shape  and  in  the  character  and  number  of 
their  branches.  Some  showed  clear  homogeneous  cell  bodies  and  some 
were  faintly  granular;  nuclei  were  sometimes  present,  sometimes  the 
cells  were  so  cut  that  the  nuclei  were  not  seen;  occasionally  cells  with 
several  nuclei  were  found.  Where  the  tissue  was  dense  the  shape  of 
the  cells  seemed  to  be  somewhat  influenced  by  mutual  pressure,  but  in 
the  looser  parts  of  the  growth  finely  branched  cells  were  common,  and 
many  large,  round,  clear,  epithelioid  cells  were  found.  Small  lymph- 
oid cells  or  nuclei,  which  stained  deeper  than  the  glia  cells,  were  found 
in  great  numbers  everywhere,  sometimes  collected  in  large  groups 
especially  in  the  vicinitv  of  blood  vessels. 

The  tibrillated  matrix  seemed  to  be  made  up,  at  least  in  part,  of  the 
branches  of  the  gliomatous  cells,  though  it  was  apparent  that  fibrous 


GOVERNMENT    HOSPITAL    FOE    THE    INSANE.  69 

tissue  was  also  present.  This  was  especially  evident  in  the  vicinity  of 
the  blood  vessels,  and  the  vessels  themselves  often  showed  thick-  walls 
composed  of  nucleated  fibrous  tisssue,  apparently  continuous  with 
loose  fibrous  tissue  in  the  vicinity-  Numerous  blood  vessels  of  large 
size  were  found  in  all  parts  of  the  growth;  they  were  uniformly  filled 
with  blood  cells  and  sometimes  contained  groups  of  leucocytes.  Some 
blood  channels  of  rather  large  size  showed  very  imperfectly  developed 
Avails;  in  none  of  the  vessels  could  muscle  cells  be  demonstrated  in  the 
walls. 

A  peculiar  feature  was  found  in  one  of  the  tissue  blocks  sectioned. 
A  small  area  was  found  containing  groups  of  cells  of  epithelial  type, 
aranged  in  alveoli,  exactly  resembling  cancer.  No  other  cell  groups 
of  this  kind  were  found,  nor  was  there  any  tendency  toward  this 
arrangement  in  any  other  part  of  the  growth.  In  fig.  4S  I  have 
represented  this  structure  at  the  right-hand  side  of  the  drawing.  This 
structure  is  seen  to  be  separated  from  the  true  gliomatous  tissue  on 
the  left  by  a  band  of  somewhat  more  condensed  and  fibrous  tissue,  and 
the  alveolar  walls  are  composed  of  the  same.  In  fig.  47  the  ordinary 
structure  of  the  tumor  is  represented;  no  alveolar  arrangement  was 
found  in  the  true  gliomatous  tissue/' 

The  brain  was  not  generally  examined.  Near  the  boundary  of  the 
tumor  the  blood  vessels  were  dilated,  filled  with  blood,  and  in  the 
vicinity  of  some  were  accumulations  of  nuclei,  and  small  hemorrhages 
were  common.  The  boundaries  of  the  tumor  were  indefinite;  there 
appeared  to  be  a  gradual  increase  of  nuclei  or  the  neuroglia  cells  as 
the  tumor  structure  was  approached;  these  began  to  show  elongated 
cell  bodies,  which  gradually  showed  as  large,  irregular  tumor  cells, 
and  the  matrix  became  fibrillated. 

In  the  uninvaded  brain  tissue  the  glia  cells  were  not  numerous  b}T 
Ordinary  stains.  A  few  were  found  presenting  the  usual  appearances 
of  these  elements.  There  was  no  increase  of  the  usual  spider  cells  in 
the  vicinity  of  the  tumor.  The  nerve  cells  showed  degenerative 
changes  and  some  enlargement  of  the  pericellular  spaces  in  the  por- 
tions adjoining  the  tumor. 

The  lungs  were  not  examined  with  the  microscope.  The  spleen 
showed  some  chronic  passive  hyperemia.  Kidneys  contained  a 
decided  increase  of  connective  tissue.  Liver  showed  slight  passive 
hyperemia. 

CASE   1619. 

GLIOMA    OF   BRAIN   AND    CAVERNOUS   ANGIOMA    OF   THE    LIVER. 

W.  L.;  aged  49;  male;  white;  single;  soldier;  nativity,  Germany 
The  patient  was  admitted  to  the  hospital  June  12,  1885,  suffering  from 
acute  maniacal  symptoms  with  homicidal  tendencies  and  delusions  of 
suspicion.  During  the  past  five  years  the  delusions  were  less  promi- 
nent; he  became  silent,  confused,  forgetful,  unable  to  express  himself 
without  great  difficulty,  and  at  last  was  completely  aphasic.  During 
the  last  two  years  of  his  life  he  grew  more  demented,  the  aphasia  was 
more  marked,  and  there  was  decided  impairment  of  hearing.  His 
sight  was  fair,   but  ophthalmoscopic  examination  was  not  made,  as 

a  My  friend,  Dr.  E.  L.  Opie,  suggests  that  the  epithelial-like  cell  groups  may  be 
inclusions,  within  the  glioma,  of  ventricular  epithelium.  This  is  quite  probable,  as 
at  one  place  the  growth  had  reached  the  lining  of  the  left  lateral  ventricle. 


70  GOVERNMENT    HOSPITAL    FOE    THE    INSANE. 

tumor  of  the  brain  was  Dot  suspected.  Epileptiform  seizures,  without 
premonition,  were  frequent.  Following  these  attacks  there  would  be 
complete  temporary  paralysis  of  the  right  side  of  the  body,  and  the 
patient  would  be  confined  to  bed  for  several  days.  The  last  convulsion, 
which  occurred  March  21,  1902,  was  followed  by  persistent  hiccough, 
prolonged  stupor, and  greater  enfeeblement,  which  remained  until  his 
death.  April  8,  L902. 

Autopsy  twenty-seven  hours  after  death.  Body  fairly  well  nourished; 
rigbr  mortis  present;  some  scars  of  scalp,  produced  by  injuries  received 
in  falls  during  convulsions;  small  abscess  of  left  ankle. 

C  'run  tu m.  —  Antero-posterior  diameter  of  skull,  7£  inches;  transverse, 
6i  inches:  shape  asymmetrical,  the  left  side  being  a  little  the  larger; 
thickness  normal:  arterial  depressions  of  left  side  large  and  deep;  Pac- 
chionian body  at  upper  end  of  left  middle  meningeal  artery  unusually 
large.  The  dura  mater  was  abnormally  tense  over  the  left  frontal 
region  and  the  subdural  space  was  dry.  and  the  surfaces  of  the  mem- 
branes were  sticky  in  this  situation  over  the  tumor. 

Brain:  Weight,  1,35(>  grams.  Surface  of  the  organ  much  compressed 
over  the  left  anterior  regions;  convolutions  flattened  against  the  tense 
dura  and  skull  bone.  In  other  regions  the  pia  contained  a  moderate 
amount  of  fluid  and  the  convolutions  showed  some  atrophy. 

The  cause  of  these  conditions  was  found  to  be  a  large  tumor  situated 
in  the  interior  of  the  left  frontal  lobe,  probably  originating  in  the  white 
matter,  and  from  its  situation  and  appearance  supposed  to  be  a  glioma. 
The  brain  was  incised  horizontally  on  a  plane  with  the  middle  of  the 
corpus  callosum,  a  section  which  passed  through  the  greatest  diameter 
of  the  tumor.  It  was  found  to  be  a  spheroidal  growth  about  2  inches 
in  diameter,  occupying  the  white  matter  and  extending  to  the  cortex, 
but  not  to  the  surface  pia  mater.  The  tumor  had  pressed  backward 
the  overhanging  portions  of  the  anterior  border  of  the  insula  and  had 
flattened  the  insular  gyri.  It  had  forced  the  basal  ganglia,  septum 
lucidum,  and  corpus  callosum  toward  the  right,  and  had  increased  the 
transverse  diameter  of  the  frontal  end  of  the  hemisphere  fully  one- 
third.  The  falx  had  been  displaced  laterally  and  was  embedded  in  the 
median  surface  of  the  hemisphere,  while  the  swollen  convolutions  of 
the  median  surface  beneath  the  falx  had  been  pressed  deeply  into  the 
opposite  surface. 

The  exact  extent  of  the  brain  involved  could  not  be  determined,  as 
the  boundaries  of  the  tumor  were  not  well  defined.  It  seemed  to  be 
situated  mainly  anterior  to  the  motor  region  of  the  brain,  and  the 
paralytic  effects  must  have  been  from  pressure.  The  third  frontal, 
middle  frontal  convolution,  and  the  white  matter  beneath  them  were 
directly  invaded,  and  judging  from  the  displacement  of  other  parts, 
the  motor  gyri  must  have  been  profoundly  injured  by  pressure.  The 
cut  surface  of  the  tumor  showed  a  pinkish  gray  color  mottled  by  dark- 
red  hemorrhagic  areas.  The  consistence  of  the  tumor  tissue  was  a  little 
denser  than  the  normal  brain,  and  that  of  the  tissue  in  the  vicinity  was 
somewhat  softer  from  (edema. 

A  few  small  softenings  were  found  in  the  lenticular  nuclei,  the 
results  of  atheroma  of  the  cerebral  arteries.  No  other  gross  lesions 
were  found  in  any  part  of  the  brain,  and  the  spinal  cord  so  far  as 
examined  seemed  normal. 

Heart:  Weight,  470  grams.  Cavities  of  right  side  filled  with  dark 
clots;  the  valves  were  not  diseased;  left  ventricle  hypertrophied;  cause 
not  apparent.     The  aorta  was  normal. 


GOVERNMENT    HOSPITAL    FOE    THE    INSANE.  71 

Thorax.  —  Lungs:  Weight  of  each,  700  grams.  Pleuritic  adhesions 
on  both  sides.  Lungs  oedematous  and  the  posterior  portions  were, 
partly  solidified  by  an  exudate  probably  inhaled  from  the  bronchi. 

Abdomen. — Spleen:  Weight,  170 grams.  The  capsule  was  wrinkled; 
pulp,  pale  and  soft. 

Kidneys:  Weight  of  each,  120  grams.  The  capsules  were  not 
abnormally  adherent  except  along  the  lines  showing  traces  of  foetal 
lobulation.  Some  atrophy  of  the  pyramids  and  slight  increase  of 
pelvic  fat. 

Bladder  showed  slight  hypertrophy  of  the  middle  lobe  of  the  prostate 
gland;  no  disease  of  the  mucous  membrane. 

Liver:  Weight  of  liver  tissue,  1,500  grams;  gall-bladder  contained 
30  c.  c.  of  normal  bile.  A  large  cavernous  angioma  in  the  upper  sur- 
face of  the  right  lobe,  and  two  of  small  size  in  the  lobulus  Spigelii. 
Otherwise  the  liver  seemed  normal. 

Other  organs  showed  nothing  of  importance. 

MICROSCOPICAL    EXAMINATION. 

The  tumor  proved  to  be  a  glioma  of  the  astroc3^tic  type  though  the 
tissue  varied  somewhat  in  structure  in  different  regions.  In  the  typ- 
ical portions  the  cells  were  of  almost  all  shapes  and  sizes,  and  whole 
fields  were  made  up  of  branched  cells  and  fibers.  Some  regions  were 
composed  mainly  of  round  cells  of  uncertain  character,  lying  in  a 
fibrillated  matrix  and  supplied  with  thin- walled  vessels,  and  again, 
other  fields  were  richly  vascular  with  a  stroma  consisting  of  fibrous 
tissue  with  elongated  nucleii  resembling  those  of  spindle  cells.  Areas 
of  degenerations  were  found  in  all  parts  of  the  tumor.  These  regions 
seemed  to  be  made  up  mainl}7  of  granular  round  cells  with  scanty 
stroma  and  a  few  persistent  thin-walled  vessels.  The  richly  vascular 
regions  are  somewhat  hard  to  explain.  They  may  be  primaril}7  areas 
of  connective  tissue  such  as  are  found  in  these  tumors,  with  telangiec- 
tasia affecting  the  capillaries  especially. 

The  drawings  represent  the  various  modifications  of  the  tissue  and 
a  field  at  the  edge  of  one  of  the  c}^sts  of  softening  found  in  some  parts 
of  the  growth. 

The  angioma  presented  no  marked  peculiarities. 

SEEIES  III    SAKC0MATA. 

Intermediate  between  the  gliomata  and  the  ordinary  sarcomata  I  have 
placed  the  tumor  found  in  case  820,  represented  by  PI.  XIX,  and  fig. 
53.  The  tumor  may  be  regarded  either  as  a  small-celled  glioma,  or,  on 
account  of  the  number  of  apparent^  mesodeimic  nuclei  present,  a 
glio-sarcoma  or  combination  tumor.  The  nuclei,  or  round  cells  seem 
to  have  some  relation  to  the  vessel  walls,  so  that  in  some  respects  it 
resembles  a  perithelial  round-celled  sarcoma. 

The  ordinary  sarcomata  are  represented  in  this  collection  by  one 
typical  tumor,  a  small,  round-celled  sarcoma,  which  seemed  to*  have 
originated  in  the  neighborhood  of  the  corpora  quadrigemina  and  thence 
spread  to  the  subthalamic  region,  cerebellum,  peduncles,  and  into  the 
posterior  horns  of  the  lateral  ventricles  as  fungous  masses. 

The  cellular  structure  of  the  tumor  presented  no  marked  peculiarities 
except  unusual  vascularity  in  some  regions  suggesting  angio-sarcoma. 


i'l  GOVERNMENT    HOSPITAL    FOR    THE    IJSSANE. 

In  some  of  the  sections  examined  were  large  bands  of  mature  con- 
nective tissue  of  uncertain  derivation,  possibly  remnants  of  the  pia 
mater. 

Some  of  the  blood  vessels  had  thick,  fibrous,  and  hyaline  walls, 
though  those  fri  the  midst  of  the  cellular  tissue  had  walls  composed  of 
flattened  endothelium  of  sarcomatous  cells  and  sometimes  a  few  invest- 
ing fibrils  of  connective  tissue. 

Some  parts,  of  the  tumor  were  considerably  degenerated,  and  in  such 
regions  an  occasional  mulberry  concretion  was  found.  These  must  be 
of  different  origin  from  those  found  in  the  dural  endotheliomata,  as 
there  are  no  cells  in  the  present  tumor  capable  of  forming  spherical 
cell  groups.  Figure  56  shows  two  of  these  concretions  lying  at  the 
edge  of  one  of  the  broad  connective  tissue  bands.  They  exactly 
resemble  those  found  in  the  pineal  gland,  choroid  plexuses,  and  in  the 
true  "brain  sand"  tumor,  or  psammoma. 

CASE  820. 

GLIO-SARCOMA    OF   BRAIN. 

H.  F. ;  aged  57;  married;  carpenter;  late  soldier;  nativity,  United 
States.  The  history  previous  to  admission  is  imperfect,  but  shows  that 
the  patient  was  admitted  to  the  National  Home  for  Disabled  Volunteer 
Soldiers,  Dayton,  Ohio,  March  IT,  1890,  with  epilepsy  and  mental 
impairment.  At  the  time  of  his  admission  to  the  Government  Hospital 
for  the  Insane,  December  31, 1890,  he  showed  some  dementia,  was  harm- 
less, but  his  mental  impairment  necessitated  restraint.  He  was  neat 
and  tidy;  would  talk  pleasantly,  but  with  some  mental  effort  to  collect 
his  thoughts.  His  habits  were  temperate,  and  his  family  history  was 
good.  After  remaining  in  the  hospital  about  four  months  he  was  sent 
to  Hampton  as  "improved,1'  but  was  returned  February  19,  1S92.  and 
remained  until  his  death,  which  occurred  April  5,  1894.  During  his 
stay  in  the  hospital  he  had  convulsive  attacks  at  intervals  of  about  a 
week,  but  no  other  symptoms  of  brain-tumor  were  observed.  The  case 
was  entered  on  the  hospital  records  as  chronic  epileptic  dementia,  dura- 
tion over  five  years. 

Autopsy,  twenty-nine  hours  after  death.  Body  well  nourished;  rigor 
mortis  present.     Only  the  brain  examined. 

Cranium. — Antero-posterior  diameter,  7-f  inches;  transverse,  5^ 
inches.  Skull  quite  thick  and  dense;  sutures  partly  united;  some 
prominence  of  inner  surface  in  the  region  of  the  coronal  suture;  shape 
of  skull  at  line  of  section  nearly  oval  and  quite  symmetrical.  On  remov- 
ing the  calvaria  the  dura  separated  readily  from  the  bone,  but  was 
slightly  adherent  to  the  pia  mater  over  the  left  temporal  lobe. 

Brain:  Weight  of  right  half,  23  ounces  (652.05  grams);  left  half,  28f 
ounces  (815.06  grams).  The  organ  showed  the  effects  of  great  intra- 
cranial pressure:  the  convolutions  were  flattened  against  the  dura,  and 
the  subdural  space  was  nearly  dry.  The  pia  mater  was  generally 
normal,  but  there  were  some  subpial  ecchymoses  over  the  lower  part 
of  the  central  convolutions  and  posterior  part  of  the  third  frontal  con- 
volution of  right  side,  and  ecchymoses  and  superficial  softenings  over 
the  temperal  lobe  and  lower  portion  of  the  central  convolutions  of  left 
hemisphere.  Almost  the  whole  of  the  surface  of  the  left  temporal 
lobe  was  very  soft,  brownish  in  patches,  and  blotched  with  small 
hemorrhages. 


GOVERNMENT    HOSPITAL    FOR    THE    INSANE.  73 

On  the  left  side  the  lower  and  anterior  pc  rtion  of  the  temporal  lobe, 
the  Island  of  Reil,  and  the  anterior  half  of  the  basal  portion  of  the 
hemisphere  were  dark  red  in  color,  swollen,  pulpy,  and  irregular  and 
tuberculated  on  the  surface.  The  convolutions  of  the  insula  were 
much  distorted  by  the  swelling,  and  the  arteries  were  deeply  embedded 
in  the  depressions  between  them.  The  uncinate  gyrus  had  swollen 
into  a  flocculus  of  pulpy  tissue,  which  projected  inward  as  far  as  the 
median  line,  overhanging  the  crus,  optic  tracts,  and  cerebral  vessels. 
A  small  portion  of  the  mass  projected  beneath  the  posterior  communi- 
cating artery.  A  depression  made  by  the  wing  of  the  sphenoid  bone 
indented  the  swollen  mass.  The  optic  nerves  and  tracts  were  pushed 
toward  the  right,  the  crus  was  slightly  flattened,  and  the  third  nerve 
was  stretched  somewhat  over  the  tumor  mass,  and  was  slightly  grayish 
in  color.  The  posterior  cerebral  artery  was  displaced  and  its  branches 
were  deeply  embedded  in  the  swollen  brain  substance.  On  the  median 
surface  of  the  hemisphere  the  brain  substance  was  pressed  beneath 
the  falx  at  least  half  an  inch  beyond  the  median  line  and  the  project- 
ing portion'had  embedded  itself  in  the  opposite  hemisphere. 

On  dissection  of  the  brain  it  was  found  that  the  changes  were  more 
extensive  than  appeared  on  the  surface.  A  large  tumor  mass  occupied 
the  interior  of  the  temporal  lobe,  and  apparently  infiltration  of  the 
brain  substance  had  extended  in  every  direction.  The  root  of  the 
olfactory  tract  appeared  to  be  affected,  the  posterior  portion  of  the 
optic  tract  showed  a  reddish  appearance  unlike  the  normal,  and  the 
third  frontal  convolution  seemed  to  be  slightly  infiltrated  at  its  posterior 
portion.  The  exact  boundaries  of  the  infiltration  could  not  be  deter- 
mined with  the  naked  eye,  as  the  general  contour  and  color  of  the 
brain  were  but  slightly  changed  at  the  supposed  periphery  of  the 
growth.  The  cortex  over  the  whole  affected  region  of  the  brain  was 
thicker  than  normal  and  darker  in  color,  and  the  white  matter  was  a 
reddish  gray  color,  somewhat  like  the  cortex.  The  tumor  tissue  was 
very  soft  and  friable  at  the  supposed  central  portion  of  the  giowth, 
but  at  the  periphery  the  tissue  gradually  assumed  tie  consistent  e  of  the 
brain  substance.  The  growth  extended  deepl}T  into  the  brain  in  every 
direction,  the  whole  depth  of  the  temporal  lobe,  the  cortex  and  white 
substance  of  the  Island  of  Reil,  the  posterior  border  of  the  third  frontal 
convolution,  and  the  posterior  portions  of  the  orbital  convolutions  all 
showed  signs  of  infiltration.  The  ventricle  wall,  the  fornix,  and  sep- 
tum lucidum  were  displaced  toward  the  right.  The  vessels  at  the  base 
were  considerably  displaced  by  the  growth  and  showed  small  patches 
of  opacit}'. 

The  general  consistence  of  the  brain  was  much  reduced,  the  tissue 
was  ced<  matous,  and  the  perivascular  spaces  were  visible  to  the  naked 
eye.  The  cerebellum,  pons,  medulla  oblongata,  and  the  cervical  por- 
tion of  the  spinal  cord  removed  with  the  brain,  presented  no  gross 
changes. 

MICROSCOPICAL    EXAMINATION. 

The  tumor  proved  to  be  a  glio-sarcoma.  The  cells  are  seen  to  vary 
greatly  in  size  and  shape,  and  seem  to  be  arranged  in  groups,  probably 
having  some  relation  to  the  distribution  of  capillary  blood  vessels. 
The  cells  are  round,  oval,  and  elongated,  and  a  few  were  found  to 
have  delicate  processes  radiating  from  them.  The  cell  bodies,  as  a 
rule,  are  hard  to  distinguish,  so  that  they  appeared  like  simple  nuclei 


74  GOVERNMENT    HOSPITAL    FOR    THE    INSANK. 

lying  in  a  granular  or  faintly  nbrillated  matrix  substance.  In  hardened 
sections  the  intercellular  substance  presents  a  granular  appearance, 
very  similar  to  the  gray  matter  of  the  brain. 

The  cell  growth  extends  into  the  brain  substance  in  every  direction; 
sometimes  converting  it  into  a  cellular  tissue:  sometimes  Leaving  the 
nerve-cells  and  other  normal  brain  structures  distinguishable.  When 
the  cortex  is  involved  the  outer  layer  seems  to  be  more  affected  than 
portions  lower  down.  A  curious  feature  in  some  areas  is  the  invasion 
of  the  enlarged  pericellular  spaces  by  the  tumor  cells:  sometimes  the 
nerve-cells  are  literally  crowded  out  by  the  invading  cells.  In  some 
convolutions  invaded  by  the  tumor  cells  the  neuroglia  of  the  gray 
matter  seems  to  be  coarsely  fibrous,  and  many  spider  cells  are  found, 
but  it  docs  not  seem  that  these  cells  enter  to  any  great  extent  into  the 
growth  of  the  tumor. 

In  some  parts  of  the  tumor  large,  tortuous,  thin-walled  blood  vessels 
are  very  numerous,  giving  almost  a  cavernous  appearance  to  that  por- 
tion of  the  growth.  Capillary  vessels  are  very  numerous  in  some 
areas,  some  small  hemorrhages  are  found,  and  occasionally  a  tortuous 
vessel  with  some  pigment  and  an  abnormal  number  of  nuclei  in  its 
perivascular  space. 

The  nerve-cells  generally  show  some  degeneration,  but  the  shapes  of 
the  cell  bodies  are  well  preserved,  even  in  .sections  bordering  on  the 
tumor.  In  the  swollen  convolutions  the  nuclear  network  seems  coarser, 
and  the  protoplasm  of  the  cell  bodies  is  granular  and  often  pigmented. 

CASE  1237. 
SMALL    ROUND-CELLED   SARCOMA    OF   THE    BRAIN.  • 

C.  E.  M. ;  aged  53;  white;  married;  messenger  in  War  Department, 
United  States;  nativity,  Maryland.  Mental  disease,  chronic  dementia 
from  tumor  of  the  brain,  duration  unknown.  The  early  symptoms  in 
this  case  were  depression,  loss  of  memory,  inattention  to  duties,  and 
delusions  of  apprehension.  He  was  admitted  to  the  Government  Hos- 
pital for  the  Insane  July  13,  1897,  with  the  above  history,  his  mental 
failure  advanced.  His  symptoms  gradually  became  worse;  he  became 
bedridden,  very  weak,  emaciated,  and  had  numerous  bed  sores.  He 
suffered  from  persistent  headache,  had  attacks  of  vertigo,  and  occa- 
sional vomiting.  His  speech  was  incoherent;  the  pupils  were  dilated; 
there  was  ptosis  of  both  eyelids:  he  became  totally  blind,  and  partially 
deaf.  The  temperature  was  persistently  above  the  normal;  he  had 
constipation  alternating  with  diarrhea;  the  urine  was  at  times  retained; 
finally  the  discharges  became  involuntary.  December  2-J-.  1897,  he 
died  from  exhaustion.  The  duration  of  the  disease  could  not  be 
determined. 

Autopsy  seventeen  hours  after  death.  Body  emaciated;  evidences 
of  bed  sores  over  sacrum,  and  trochanters:  rigor  mortis  present. 

Cranium. — Antero-posterior  diameter  of  the  skull  7£  inches;  trans- 
verse, 5f  inches.  Sutures  normal;  shape  symmetrical;  bone  of  usual 
thickness.  Dura  mater  was  not  generally  abnormally  adherent,  but 
in  the  anterior  portions  of  the  middle  cerebral  fossse  the  bone  was 
absorbed  in  little  depressions,  and  into  these  the  dura,  pia,  and  brain 
cortex  had  been  forced  by  intracranial  pressure  as  small  hernias. 

Brain:  Weight,  with  the  tumor,  48  ounces  (1,300.8  grams).  The 
subdural  space  was  somewhat  drier  than  usual,  and  the  dura  mater  was 


GOVERNMENT    HOSPITAL    FOR   THE    INSANE.  75 

drawn  tightly  over  the  brain  by  intracranial  tension.  The  arteries  at 
the  base  were  moderately  full  of  blood  but  not  diseased.  The  floor  of 
the  third  ventricle  was  bulged  downward,  and  the  optic  commissure 
was  greatly  thinned  by  the  pressure  of  the  intraventricular  fluid;  the 
optic  nerves  were  smaller  than  normal.  The  brain  was  flabby  and 
soft;  convolutions  somewhat  shrunken  and  flattened  at  their  summits 
by  pressure  against  the  dura  mater  and  skull  bone. 

'  Dissection  of  the  brain  revealed  a  tumor  growth,  which  appeared 
to  have  originated  in  the  region  of  the  corpora  quadrigemina,  and 
thence  extensively  invaded  the  brain.  It  had  extended  along  the  supe- 
rior cerebellar  peduncles  and  formed  masses  in  the  cerebellum;  out- 
ward into  the  cerebral  hemispheres  and  then  involved  the  basal  region 
at  the  junction  of  the  occipital  and  temporal  lobes,  and  grew  into  the 
posterior  horns  of  the  ventricles  as  fungoid  masses.  Small  fungoid 
masses  had  extended  forward  along  the  lateral  walls  of  the  third  ven- 
tricle. The  corpora  quadrigemina,  conarium,  valve  of  Vieussens,  and 
upper  part  of  the  cerebellar  peduncles  were  totally  destroyed  and 
indistinguishable.  The  complete  obstruction  of  the  aqueduct  of  Syl- 
vius was  no  doubt  the  cause  of  the  great  distention  and  enlargement 
of  the  ventricles. 

The  tumor  tissue  was  extremely  soft  and  easily  torn,  and  this,  with 
the  inflammatory  adhesions,  made  the  dissection  very  difficult.  Section 
of  the  growth  showed  the  tissue  to  be  very  vascular;  reddish  gray  in 
color;  somewhat  degenerated  in  the  central  portions,  and  the  knife 
came  in  contact  with  gritty  particles  in  cutting  through  it. 

When  the  tumor  invaded  the  brain  substance  it  was  separated  from 
the  normal  tissue  by  a  definite  boundary  line,  and  when  the  growth 
penetrated  pre  formed  spaces,  such  as  the  posterior  and  inferior  horns 
of  the  ventricles,  the  new  growth  seemed  to  conform  to  the  shape  of 
the  space  occupied. 

.  In  the  vicinity  of  the  tumor  the  brain  substance  was  very  soft  and 
eedematous;  tissue  in  general  was  pale;  ventricles  dilated;  ependyma 
smooth;  gray  commissure  was  greatly  stretched,  but  not  torn.  Noth- 
ing abnormal  was  noted  in  the  medulla  and  spinal  cord.  Other  organs 
were  not  examined. 

MICROSCOPICAL   EXAMINATION. 

The  tumor:  The  growth  proved  to  be  a  small  round-celled  sarcoma, 
which  probably  originated  in  the  membranes  in  the  vicinity  of  the 
corpora  quadrigemina.  The  great  bulk  of  the  tumor  consisted  of 
round  cells,  with  relatively  large  nuclei  and  small  protoplasmic  cell 
bodies.  The  intercellular  substance  was  scanty,  appeared  granular, 
but  a  few  delicate  fibers  were  found.  Numerous  sarcomatous  blood 
vessels  were  found  in  the  cellular  tissue,  in  some  places  suggesting 
angiosarcoma,  and  the  grouping  of  the  cells  in  the  vicinity  of  the  ves- 
sels, seen  in  some  places,  is  also  suggestive  of  some  relation  between 
the  cell  development  and  the  vessels.  Very  little  connective  tissue  was 
found  in  the  main  cell  masses  of  the  tumor,  but  in  the  vicinity  of  the 
pia  mater  some  bands  of  fully  developed  fibrous  tissue  were  found, 
which  were  supposed  to  be  distorted  remnants  of  the  membranes, 
incorporated  with  the  sarcomatous  growth.  Some  large  blood  vessels 
were  found  in  this  tissue.  In  the  degenerated  areas  of  the  tumor, 
where  the  gritty  particles  were  detected  by  the  knife,  were  numerous 


76  GOVERNMENT    HOSPITAL    FOR    THE    INSANE. 

irregularly  rounded,  concentrically  striated,  and  sometimes  mulberry- 
shaped,  highly  refractile  bodies,  supposed  to  be  what  is  commonly 
called  "brain  sand."  They  are  supposed  by  the  writer  to  be  of  dif- 
ferent structure  and  origin  from  the  somewhat  similar  spherules  found 
in  many  of  the  spindle-celled  sarcomata  of  the  dura  mater.  (Sec 
description  of  fig.  56.)  The  calcareous  spherules  were  not  found  in 
the  cell  tissue  of  the  growth  except  in  the  degenerated  areas,  where 
they  were  associated  with  remnants  of  connective  tissue.  Some  gran- 
ular calcareous  infiltration  was  found  in  the  small  cerebral  vessels  at 
the  boundaries  of  the  invading  tumor.  Though  the  tumor  undoubt- 
edly extended  locally  by  invasion  and  infiltration  of  adjacent  tissues, 
the  microscope  showed  remarkably  defined  limits  to  the  growth  when 
normal  tissue  was  invaded.  The  boundary  line  of  the  growth  was 
often  distinct,  even  when  the  pia  mater  was  the  tissue  in  advance  of 
the  growth.  In  this  respect  this  tumor  presented  a  marked  contrast 
with  glioma  and  glio-sarcomata,  as  in  these  no  definite  boundaries  can 
be  made  out. 

Brain:  The  membranes  generally  were  normal.  The  blood  vessels 
were  somewhat  tortuous  and  had  some  pigment  granules  in  their  peri- 
vascular spaces,  but  were  not  otherwise  diseased.  The  brain  cells 
showed  various  degrees  of  granular  pigmentary  degeneration.  The 
cells  of  cerebellum  and  spinal  cord  were  pigmented,  and  some  in  the 
latter  were  quite  granular. 

SEKIES  IV.  HYPOPHYSEAL  TUMOKS. 

Three  tumors  of  the  collection  occupied  the  pituitary  fossa?,  two 
were  adenomata  of  the  hypophysis,  and  one  was  situated  in  the  fossa 
and.  had  greatly  enlarged  it.  but  did  not  involve  the  pituitary  gland. 

In  the  two  cases  of  adenoma  the  tumors  were  large  and  had  greatly 
enlarged  the  pituitary  fossae,  and  had  pressed  injuriously  upon  the 
structures  in  the  vicinity  and  the  brain;  }Tet  in  neither  case  were  there 
any  signs  of  acromegaly,  myxoedema,  or  allied  conditions.  So  far  as 
could  be  determined  the  thyroid  glands  were  normal  in  all  of  the  cases. 

In  the  study  of  these  tumors,  made  some  time  ago,  the  writer  has 
not  been  able  to  satisfy  himself  as  to  the  chromophilic  character  of  the 
cells:  but  the  marked  differences  in  the  size,  shape,  and  arrangement 
of  the  cells  in  the  normal  gland  were  surprisingly  repeated  in  the 
tumor  found  in  case  788.  A  marked  characteristic  of  this  tumor,  in 
which  it  differs  from  the  normal  gland  and  from  the  tumor  to  follow, 
was  in  the  development  of  papillary  ingrowths  from  the  alveolar  walls. 
In  some  regions  the  papillae  were  so  elongated  and  ramified  as  to 
almost  fill  the  large  acini.  In  some  parts  of  the  growth  the  alveolar 
spaces  were  very  large,  and  wTere  completely  filled  with  small  rounded 
cells,  giving  to  the  tissue  a  superficial  resemblance  to  alveolar  sarcoma. 

In  case  87o  there  was  little  tendency  to  development  of  papillary 
growths.  The  alveoli  were  very  large  and  lined  with  long  columnar 
cells,  sometimes  more  than  one  layer  deep,  the  more  superficial  cells 
lying  wedged  between  the  deeper  layers.  Usually  some  free  cells 
were  found  in  the  central  portions  of  the  alveoli,  and  transverse  views 
of  the  columnar  cells  presented  the  appearance  of  pavement  epithe- 
lium in  some  parts  of  acini  so  sectioned. 

The  structure  of  this  tumor  appeared  quite  uniform  in  all  parts 
examined,  and  from  the  appearance  of  the  cells  and  their  arrangement 


GOVERNMENT    HOSPITAL    FOR    THE    INSANE.  77 

I  should  conclude  that  the  growth  was  composed  almost  exclusively 
of  the  large  columnar  type  of  cells  such  as  are  found  at  the,  posterior 
border  of  the  prehypophysis.  The  cells  stained  deeply  in  eosin  and 
appeared  finely  granular  under  high  amplification,  but  so  far  as  could 
be  determined  all  were  alike  in  staining  reactions. 

The  connective-tissue  stroma  much  resembled  that  of  the  normal 
gland,  though  the  amount  was  relatively  less,  the  alveoli  being  very 
large  in  both  tumors.  The  stroma  was  well  supplied  with  blood  ves- 
sels and  each  papillary  process  contained  one  or  more  large  vessels 
and  a  small  amount  of  cellular  connective  tissue. 

The  third  tumor  of  this  series  was  completely  degenerated,  and  its 
structure  could  not  be  determined.  It  had  evidently  been  of  consid- 
erable bulk,  as  the  pituitary  fossa  was  enlarged  to  at  least  four  times 
the  normal  size.  It  was  not  a  true  tumor  of  the  hypophysis,  as  the 
gland  was  found  situated  posterior  to  the  growth  and  apparently  nor- 
mal. Though  there  must  have  been  at  one  time  during  the  growth  of 
the  tumor  great  pressure  on  and  displacement  of  the  structures  in  the 
pituitary  region  and  the  base  of  the  brain,  there  were  no  signs  of 
acromegalia  in  this  case. 

Though  it  is  possible  that  obscure  signs  of  the  disease  may  have 
escaped  the  observation  of  the  clinicians  and  the  pathologist,  we  have 
here  two  cases  of  adenoma,  or  hyperplasia,  of  the  hypophysis  without 
the  usual  easily  recognized  signs  and  symptoms  of  a  acromegalia, 
though  the  tumors  had  reached  large  size;  and  in  the  last  case  we  have 
some  evidence  against  the  theory  of  pressure  as  a  causative  factor  in 
the  disease. 

CASE  788. 

ADENOMA    OF   THE   PITUITARY    BODY. 

M.  J.T. ;  aged  75;  widow;  domestic;  colored;  nativity,  United  States. 
Mental  disease,  chronic  dementia,  duration  unknown.  ^Yhen  she  was 
admitted  to  the  hospital  she  had  a  fair  degree  of  mental  power,  which 
was  retained  during  her  stay  in  the  hospital  until  about  two  weeks 
before  her  death.  She  had  at  that  time  a  severe  convulsion,  followed 
by  milder  attacks  for  a  few  days;  after  this  she  became  restless  and 
excited,  and  so  continued  until  her  death.  Mo  ophthalmoscopic  exam- 
ination was  made,  but  her  attendants  claim  that  she  was  totally  blind 
for  some  time  before  she  died.  Some  pain  in  the  head  was  complained 
of,  but  it  was  not  severe  enough  to  elicit  much  complaint;  vomiting 
was  not  observed  during  the  time  she  was  in  the  hospital. 

Autopsy  twelve  hours  after  death.     Body  well  nourished. 

Cranium. — Antero-posterior  diameter,  7i  inches;  transverse,  5i 
inches.  Skull  rather  thick,  but  not  unusually  so  for  a  colored  person; 
dura  not  abnormally  adherent. 

Brain:  Weight,  43  ounces  (1,219.05  grams).  On  removing  the  brain 
a  tumor  of  globular  shape  was  found  at  the  base,  projecting  from  the 
pituitary  fossa.  The  tumor  was  nearly  an  inch  and  a  fourth  in  its 
average  diameter,  and  was  irregularly  globular  in  shape.  The  pitu- 
itary fossa  was  greatly  enlarged  to  accommodate  it;  the  antero- 
posterior diameter  was  an  inch  and  an  eighth,  the  transverse  was  an 
inch  and  a  quarter,  the  depth  three-fourths  of  an  inch.  The  anterior 
clinoid  processes  could  be  distinguished,  but  the  posterior  pair  were 
destro}7ed  by  the  growth  of  the  tumor.     The  bottom  of  the  fossa  and 


78  GOVERNMENT    HOSPITAL    FOR    THE    INSANE. 

the  anterior  portion  of  the  basilar  process  showed  the  effects  of  absorp- 
tion, and  the  dura  mater  at  the  bottom  of  the  fossa  was  partly 
destroyed.  On  removing  the  tumor  from  the  fossa  the  left  cavernous 
sinus  was  opened  and  a  portion  of  the  carotid  artery  adhered  to  the 
tumor,  showing  that  pressure  must  have  been  exerted  upon  the  con- 
tents of  the  cavernous  sinus. 

The  tumor  had  embedded  itself  in  the  base  of  the  brain  in  the  center 
of  the  circle  of  Willis,  and  a  careful  removal  of  it  showed  that  it  took 
the  place  of  the  pituitary  body,  and  the  depression  in  the  brain  was 
over  the  normal  situation  of  that  body.  The  depression  in  the  brain 
was  about  half  an  inch  in  depth  and  an  inch  and  a  quarter  in  diameter. 
The  optic  nerves,  chiasma,  and  the  anterior  position  of  the  optic  tracts 
were  flattened  out  ana  the  nerves  were  nearly  cut  off  by  being  pressed 
against  the  anterior  cerebral  arteries.  The  vessels  composing-  the  cir- 
cle of  Willis  were  all  thrust  out  of  place  by  the  tumor;  the  corpora 
albicantia  were  flattened  slightly;  the  floor  of  the  third  ventricle  was 
pushed  upward;  the  roots  of  the  olfactory  nerves  were  pressed  apart. 
and  there  was  slight  pressure  on  the  crura  cerebri.  A  portion  of  the 
tuber  cinereum  could  still  be  seen  at  the  bottom  of  the  depression,  and 
a  band  of  tissue  from  it  joined  to  the  tumor;  removal  of  the  tumor 
brought  away  the  band  and  thereby  opened  the  third  ventricle.  The 
tumor  was  believed  to  be  an  adenoma,  or  overgrowth  of  the  pituitary 
body,  and  such  it  proved  to  be  on  further  examination.  Section  of  the 
growth  showed  it  to  be  composed  of  soft,  pale,  reddish-gray  tissue, 
apparently  of  similar  composition  throughout.  The  tissue  was  quite 
moist,  but  no  actual  juice  exuded  from  it.  It  had  a  distinct  fibrous 
capsule,  in  which  large  blood  vessels  could  be  seen,  and  the  growth 
was  supplied  with  blood  in  the  same  way  as  the  normal  body. 

The  specimen  was  deemed  of  sufficient  importance  to  justify  a  sacri- 
fice of  the  brain,  which  would  probably  only  show  the  usual  degenera- 
tive changes,  and  therefore  it  was  preserved  in  alcohol  as  a  museum 
specimen.  The  examination  of  the  exterior  of  the  brain  showed  slight 
general  atrophy  of  the  convolutions  and  the  depression  above  described 
in  the  basal  region;  but  there  were  no  gross  lesions  of  the  cortex,  and 
no  effects  of  pressure  were  noticeable  over  the  convexity. 

Thorax. — Lungs:  The  left  weighed  10  ounces  (283.50  grams);  right, 
Hi  ounces  (326.02  grams).     The  appearances  were  perfectly  normal. 

Heart:  Weight,  12|- ounces  (354.37  grams).  Pulmonary  valves  nor- 
mal; edges  of  tricuspid  valve  a  little  thickened:  aortic  valves  slightly 
thickened  and  contracted;  mitral  valve  thickened  at  its  edges,  and  had 
3"ellow  patches  at  its  base.  Wall  of  right  ventricle  thin  and  encroached 
upon  by  the  superficial  fat. 

Abdomen. — Spleen:  Weight,  H  ounces  (12.52  grams).  Capsule 
tense;  tissue  fibrous. 

Kidneys:  Weight  of  each,  3£  ounces  (92.13  grams).  Capsules 
adherent;  surfaces  granular  and  cystic;  cortex  thin;  pyramids  atro- 
phied.    Urinary  bladder  normal. 

Liver:  Weight,  39£  ounces  (1,119.82  grams).  Capsule  over  right 
lobe  adherent  to  the  diaphragm;  tissue  normal;  gall  bladder  contained 
dark  bile  and  a  few  small  calculi. 

Uterus  and  ovaries:  On  the  anterior  wall  of  the  uterus  was  a  pedun- 
culated tumor,  and  two  or  more  small  intramural  tumors  were  found 
in  the  body.  The  upper  portion  of  the  cervix  was  constricted  and  the 
cavity  was  dilated,  and  at  the  fundus  was  a  cystic  growth  about  an  inch 


GOVERNMENT    HOSPITAL    FOR   THE    INSANE.  79 

in  diameter.     The  position  was  that  of  retroflexion,  and  uterus  and 
ovaries  were  adherent  in  the  recto-uterine  pouch.     The  uterine  arteries 

were  tortuous  and  rigid;  the  ovaries  were  atrophied. 
Other  organs  were  normal. 

MICROSCOPICAL   EXAMINATION. 

The  tumor  was  found  to  be  an  adenoma,  or  hypertrophy  of  the  anterior 
or  epithelial  lobe  of  the  pituitary  body.  Sections  from  normal  adult 
hypophyses  are  represented  by  camera  lucida  drawings  for  comparison 
with  those  drawn  to  the  same  scale  from  the  tumor.  The  different  por- 
tions of  the  tumor  varied  so  greatly  in  structure  on  account  of  peculiar- 
ities of  growth,  and  probably  differences  of  origin,  that  it  seemed  neces- 
sary to  represent  several  fields  for  comparison.  By  comparing  the  tumor 
specimens  with  the  normal  it  is  easily  seen  that  all  the  cell  elements 
found  in  the  tumor  have  their  prototypes  in  the  normal  gland,  and  that 
even  the  arrangement  of  the  normal  is  usually  closely  copied  by  the 
abnormal  growth. 

There  are.  however,  points  of  difference  due  to  irregular  develop- 
ment and  growth,  which  make  the  study  of  this  tumor  extremely  inter- 
esting. 

The  simplest  portion  of  the  tumor  for  study  is  that  which  is  found 
in  the  denser  portion  of  the  growth  and  presents  an  alveolar  arrange- 
ment as  shown  in  tigs.  60,  61,  and  62.  By  comparison  with  the  normal 
the  alveoli  are  seen  to  be  larger,  the  connective  tissue  septa  are  larger, 
and  the  columnar  cells  around  the  periphery  are  more  regularly  devel- 
oped in  fig.  00.  In  fig.  61  the  acini  are  larger,  but  they  are  almost  per- 
fect reproductions  of  the  small-celled  acini  in  fig.  57,  from  the  normal. 
The  duct-like  acinus  has  its  normal  prototype  in  the  ducts  which  are 
found  in  the  normal  at  the  posterior  border  of  the  anterior  lobe,  and 
represented  in  fig.  59,  drawn  from  this  region.  Figure  62,  from  the 
tumor,  represents  alveoli  without  a  trace  of  columnar  cells  around  the 
periphery.  This  variety  of  tissue  only  exists  in  small  areas  here  and 
there,  through  the  tumor.  This  variety  of  tissue  I  think  must  have 
developed  from  alveoli  with  similar  cells  and  cell  arrangement  seen  in 
the  normal  in  figs.  58  and  59.  In  the  tumor  such  fields  bear  a  strik- 
ing resemblance  to  cancer.  In  the  alveolar  structure  of  the  tumor  no 
lumen  is  preserved,  as  a  rule,  whereas  in  the  normal  many  of  the  acini 
show  central  openings. 

The  most  remarkable  deviation  from  the  normal  is  found  in  the 
looser  portions  of  the  tumor,  represented  in  figs.  63  and  64.  This 
tissue  showrs  whole  fields  made  up  of  papillary  and  elongated  and 
branched  processes  of  fibrous  tissue,  surrounded  by  long  columnar 
cells.  That  these  ramifying  processes  are  more  or  less  cylindrical  is 
shown  by  the  transverse  sections  of  them  seen  in  figs.  63  and  64.  The 
central  core  of  fibrous  tissue  carries  the  blood  vessels  just  as  the  septa 
do  in  the  alveolar  portion  of  the  growrth.  The  long  cylindrical  pro- 
cesses ramify  and  run  in  every  direction,  so  that  in  sections  they  are 
cut  in  every  possible  wajT,  as  may  be  seen  in  fig.  63. 

Between  the  papillary  processes  small  roundish  cells  are  found:  in 
some  fields  the  interpapillary  spaces  are  completely  filled  up  with  the 
cells;  in  other  regions  the  spaces  are  nearly  empty,  or  probably  con- 
tained fluid  during  life. 

By  examining  fig.  60  carefully  we  may  gain  some  insight  into  the 
mode  of  growth  of  these  papillary  processes.     It  will  be  seen  that 


80  GOVERNMENT  hospital  for  the  insane. 

small  papillae  grow  from  the  septa  into  the  cavity  of  the  alveoli  among 
the  cells.     Now.  if  we  imagine  these  alveolar  spaces  greatly  enlarged, 

and  the  papillary  processes  growing  into  them  in  every  direction 
among  the  loose  cells,  we  would  have  a  picture  similar  to  parts  of  tig*. 
63.  It  is  rather  more  probable  that  certain  parts  of  the  growth  became 
cystic,  and  that  the  papillary  processes  grew  into  these  cysts  until  they 
were  completely  tilled  up  by  them,  and  that  the  loose  cells  are  prod- 
ucts of  cell  proliferation  which  occurs  later,  either  from  the  papilla?  or 
from  the  original  alveolar  walls.  Whatever  may  be  the  mode  of 
growth  of  these  papillary  processes,  the  condition  is  a  common  one  in 
the  adenomata,  especially  the  cystic  kind. 

It  is  interesting  to  observe  that  the  tendency  to  colloid  degeneration 
which  exists  in  the  normal  pituitary  body  is  seen  in  certain  structures 
in  the  adenoma;  compare  tigs.  59  and  61.  The  duct-like  acini  contain 
a  faintly  granular  material  which  is  supposed  to  be  colloid,  as  in  the 
thyroid  gland. 

In  the  adult  pituitary  bodies  studied  to  compare  with  the  adenoma, 
I  have  not  been  able  to  demonstrate  cilia  on  the  columnar  cells  lining 
the  large  duct-like  cavities  situated  at  the  junction  of  the  two  lobes, 
but  it  is  claimed  that  the  cells  are  ciliated  (Weichselbaum). 

The  brain  was  preserved  as  a  museum  specimen  and  was  therefore 
not  examined  with  the  microscope. 

The  kidneys  showed  a  decided  degree  of  interstitial  nephritis. 

The  uterine  tumors  were  fibfo-myomata,  one  of  which  was  cystic. 

The  other  organs  presented  nothing  of  especial  interest  in  addition 
to  the  naked-eye  diagnosis. 

CASE  870. 

ADENOMA    OF   THE    PITUITARY   BODY. 

J.  M.  C. ;  aged  56  years;  married;  farmer;  former  soldier;  nativity, 
United  States.  Mental  disease,  chronic  dementia;  duration  about  two 
years  and  nine  months.  This  case  was  remarkable  for  the  large  size 
of  the  tumor;  the  absence,  so  far  as  could  be  ascertained,  of  the  usual 
symptoms  of  intracranial  growth,  and  the  persistence  of  some  degree 
of  sight  with  great  pressure-atrophy  of  optic  nerves  and  chiasma.  The 
following  clinical  history  wras  furnished  me  by  my  colleague  Dr. 
Foster: 

"J.  M.  C.  was  admitted  to  the  hospital  December  6,  1893;  died 
September  10.  1894.  Condition,  anaemic,  feeble,  apathetic,  confined 
to  bed;  no  thoracic  or  abdominal  disease  apparent.  Knees  flexed  at 
right  angles,  with  contracture  of  leg  flexors.  Complains  of  pain  in 
knees;  is  contented  to  lie  quietly  in  bed;  has  good  appetite:  mental 
processes  slow  and  feeble;  untidy  in  habits.  The  pupils  were  rather 
large  and  sluggish,  but  equal,  and  no  external  ocular  paralysis  existed. 

"He  could  see  sufficiently  for  his  needs  in  his  demented  condition, 
being  able  to  feed  himself.     Acuteness  of  vision  was  not  tested. 

"The  knee  pains  were  relieved  by  sodium  salicylate  and  did  not 
recur.  He  gradually  failed  and  died  without  other  symptoms  than 
exhaustion. 

"After  his  death  it  was  learned  by  correspondence  that  five  years 
before  his  admission  his  sight  had  failed  until  he  could  barely  see,  but 
not  recognize,  a  person  standing  in  front  of  him.  His  chief  complaint 
was  of  being  tired  and  of  back  ache,  the  latter  being  attributed  to  an 
injury  received  while  in  the  service. 


government  hospital  for  the  insane.  81 

"He  did  not  complain  of  headache,  and  the  usual  symptoms  of 
tumor  of  the  brain  were  all  wanting  during  his  stay  in  the  hospital; 
nor  could  any  be  recalled  by  his  widow  wnen  questioned  by  letter. 
There  were  no  symptoms  whatever  of  acromegaly." 

Autopsy  thirteen  hours  after  death:  Body  somewhat  emaciated; 
skin  anaemic  and  slightly  yellowish;  pubic  and  axillary  legions  devoid 
of  hair;  yellowish-brown  patches  of  pigmentation  over  the  lower 
extremities;  bedsores  over  both  trochanters. 

Cranium,. — The  skull  was  of  the  usual  thickness,  and  the  born:  was 
rather  dense;  the  sutures,  including  the  frontal,  were  visible  exter- 
nally but  were  indistinct  in  the  inner  table;  arterial  depressions  well 
marked.  The  shape  was  slightly  asymmetrical;  antero-posterior  diam- 
eter, 7i  inches;  transverse  diameter,  5£  inches. 

Removal  of  the  brain  revealed  a  large  tumor  occupying  the  posi- 
tion of  the  pituitary  body,  and  the  fossa  was  greatly  enlarged.  When 
the  tumor  was  dissected  out,  the  cavity  measured  l-£  inches  antero- 
posterior^, If  inches  in  transverse  diameter,  and  about  1  inch  in 
depth.  The  surface  of  the  bone  in  and  around  the  cavity  was 
eroded  and  roughened  b}^  absorption,  and  the  clinoid  processes  and 
normal  borders  of  the  fossa  were  destroyed  in  the  same  way. 

The  dura  mater  was  somewhat  thickened  along  the  superior  longi- 
tudinal sinus,  but  was  not  abnormally  adherent  to  the  bone  except 
around  the  margins  of  the  enlarged  pituitary  fossa. 

Brain:  The  weight  with  the  tumor  was  48  ounces  (1,360.80  grams). 
The  pia  mater  showed  opacity,  thickening,  and  some  unusual  adhesion 
to  the  dura  along  the  margins  of  the  great  longitudinal  fissure,  and 
some  opacity  over  the  whole  convexity,  especially  along  the  veins. 
The  pial  veins  were  full  of  blood;  arteries  at  the  base  were  atheroma- 
tous and  displaced  by  the  tumor.  The  convolutions  were  somewhat 
atrophied  over  the  f ronto-parietal  convexity,  but  there  was  no  flatten- 
ing of  their  summits  nor  other  sign  of  increased  intracranial  tension, 
and  the  cerebro-spinal  fluid  was  increased. 

The  tumor  occupied  the  place  of  the  pituitary  body  and  appeared  to 
be  an  enlargement  of  the  same.  It  protruded  from  the  base  and  pene- 
trated deeply  into  the  ventricular  cavity  of  the  brain.  As  nearly  as 
could  be  determined,  the  growth  measured  1^  inches  in  transverse  diam- 
eter, 2  inches  antero-posteriorry,  and  was  about  2  inches  in  vertical 
diameter.  Much  the  greater  bulk  of  the  tumor  was  outside  the  pitui- 
tary fossa  and  had  penetrated  the  brain  cavities,  as  may  be  seen  in  the 
median  section  of  the  brain.     (PI.  XXV.) 

The  carotid  and  posterior  communicating  arteries  were  widely  sepa- 
rated, and  the  nutrient  systems  of  small  vessels  which  arise  from  the 
carotid  and  other  arteries  over  the  anterior  perforated  spaces  were  partly 
drawn  from  their  places.  The  optic  nerves  were  flattened  and  the  chi- 
asma  stretched  over  the  tumor  and  greatly  thinned,  and  the  optic  tracts 
were  widely  separated  and  flattened  by  the  encroachment  of  the  growth. 
The  third  nerves  were  slightly  compressed  between  the  tumor  and  the 
pons,  and  the  inner  and  anterior  portions  of  the  crura  were  slightly 
indented.  The  parts  which  form  the  floor  of  the  third  ventricle  were 
completely  destroyed  and  the  growth  had  extended  upward  into  the 
ventricular  cavity,  pressed  aside  and  embedded  itself  in  the  walls  of  the 
third  ventricle  and  the  thalami,  and  encroached  upon  the  caudate  nuclei 
posteriorly.     The  upper  part  of  the  tumor  was  almost  in  contact  with 

24648—03 6 


82 —  GOVERNMENT    HOSPITAL    FOR    THE    INSANE. 

the  under  .surface  of  the  fornix,  and  the  velum  interposition  was  slightly 
adherent  to  it.  The  optic  nerves,  chiasma,  and  arteries  were  adherent 
to  the  growth,  and  had  to  be  dissected  from  it  for  complete  examina- 
tion. The  roots  of  the  olfactory  tracts  were  widely  separated  but 
apparently  not  directly  pressed  upon. 

The  tumor  seemed  to  have  a  firm  connective  tissue  capsule,  but  the 
interior  was  of  soft  consistence  generally,  and  a  clear  juice  exuded 
from  the  cut  surface.  *  In  the  center  was  a  small  calcareous  mass  which 
was  sectioned  with  difficulty. 

After  hardening,  the  surface  of  the  section  looked  granular  or  felt- 
like, probably  from  abstraction  of  the  juice  and  irregular  shrinkage 
of  the  tissue  elements.  The  halves  of  the  brain  were  hardened  with- 
out further  section  to  show  the  tumor  in  situ. 

The  cerebellum,  pons,  and  medulla  showed  nothing  of  importance 
so  far  as  examined. 

Thorax. — Weight  of  left  lung,  21  ounces  (595.35  grams);  right  lung, 
21£  ounces  (691.57  grams).  Slight  emphysema  of  anterior  margin; 
posterior  portions  hypostatic;  shallow  scars  of  pleura  at  the  apices. 

Heart:  Weight,  7*i  ounces  (205.53  grams).  Superficial  arteries  tor- 
tuous. Pulmonary  and  tricuspid  valves  normal.  Aortic  valves  normal 
except  some  fenestra?  above  line  of  contact;  mitral  valve  slightly  thick- 
ened but  competent;  chorda?  tending  slightly  thickened;  summits  of 
muscular  papilla?  fibrous;  endocardium  of  both  ventricles  slightly 
opaque.  Arch  of  aorta  not  diseased;  some  atheroma  in  the  abdominal 
portion. 

Abdomen. — Weight  of  spleen,  5i  ounces  (155.92  grams);  capsule 
smooth;  pulp  soft  and  somewhat  slate-colored. 

Kidneys:  Weight  of  left,  5  ounces  (111.75  grams);  right,  3f  ounces 
(106.3  grams).  Capsules  adherent;  surfaces  granular;  cortex  thin; 
pyramids  darker  than  normal.     Urinary  bladder  normal. 

Liver:  Weight,  11^  ounces  (1,169.13  grams).  Capsule  of  right  lobe 
slightly  adherent  to  the  diaphragm;  liver  tissue  rather  pale.  Gall 
bladder  contained  an  ounce  of  pale,  water}*-  bile. 

Other  abdominal  organs  were  normal. 

MICROSCOPICAL   EXAMINATION. 

Tumor:  The  growth  consisted  of  an  alveolar  structure,  with  large 
spaces  filled  with  cells  and  lined  with  a  more  or  less  perfect  layer  of 
long  columnar  cells.  The  spaces  were  large  enough  to  be  visible  to  the 
naked  eye,  after  hardening  had  rendered  them  more  distinct,  thus  giv- 
ing a  felt-like  appearance  to  the  cut  surface,  as  may  be  seen  in  PI.  II. 

The  long  columnar  cells  were  very  irregularly  arranged  along  the 
alveolar  walls,  and  were  of  all  sizes  and  shapes.  Some  were  long  and 
narrow,  some  club-shaped,  some  wedge-shaped  to  fill  the  spaces  between 
the  long  tapering  cells,  and  some  were  apparently  loosening  from  their 
attachment  to  the  walls  and  becoming  shortened  and  rounded  like  the 
free  cells  in  the  center  of  the  alveoli.  At  some  places  the  lining  of  col- 
umnar cells  seemed  to  be  absent  and  the  po^gonal  central  cells  were 
in  contact  with  the  walls  of  the  alveoli.  In  the  central  portions  of  the 
alveoli  the  cells  were  of  all  shapes,  but  the  majority  were  more  or  less 
rounded  with  prominent  round  nuclei.  Some  alveoli  were  completely 
filled  to  the  la}Ter  of  parietal  cells;  some  contained  comparatively  few. 
In  nearly  all  a  space  existed  between  the  central  mass  of  cells  and  the 


GOVERNMENT    HOSPITAL    FOR    THE    INSANE.  83 

columnar  layer,  probably  due  to  shrinkage  of  the  central  mass  in  har- 
dening. It  seemed  quite  evident  from  the  appearances  of  the  columnar 
layer  above  described  that  the  central  cells  had  been  shed  off  from  the 
walls  and  had  gradually  accumulated  within  the  alveoli. 

There  was  little  indication  of  papillary  outgrowths  from  the  alveolar 
walls;  but,  with  this  exception,  the  structure  was  identical  with  the 
pituitary  adenoma  described  in  the  preceding  case,  and  represented  by 
fig.  60.  This  difference  in  mode  of  growth  is  extremely  interesting, 
as  it  furnishes  additional  proof  of  the  theory  of  the  development  of 
such  papillomatous  adenomata. 

The  alveolar  walls  were  composed  of  well -developed  fibrous  connect- 
ive tissue  carrying  numerous  blood  vessels.  No  degenerative  changes 
were  found  in  the  portions  examined,  which  did  not  include  the  small 
hardened  mass  described  in  the  naked-e}Te  examination.  A  few  of  the 
alveolar  spaces  contained  some  blood  among  the  central  cells. 

As  the  specimens  were  preserved  for  their  naked-eye  appearances, 
the  brain  tissue  was  not  examined.  The  other  organs  presented  noth- 
ing of  interest  in  addition  to  the  conditions  noted  at  the  autops}r. 

CASE  964. 

TUMOR   OF   THE   PITUITARY  FOSSA,  AND  CYST-LIKE    PROTRUSION    OF    THE 
FLOOR   OF   THE   THIRD   VENTRICLE. 

F.  J.;  aged  38  years;  colored;  single;  laborer;  nativitj^,  United 
States.  Mental  disease,  chronic  mania;  duration,  over  twenty  years. 
Terminal  dementia  was  so  far  advanced  in  this  case  that  but  little  could 
be  elicited  from  him  as  to  pain  or  other  subjective  sensations.  He  was 
paralyzed,  had  occasional  convulsions,  and  vomiting  was  sometimes 
observed.  He  grew  gradually  weaker,  the  paralysis  became  more 
general,  bed  sores  formed,  and  death  occurred  from  exhaustion. 

Autopsy  sixteen  hours  after  death.  Body  emaciated;  bed  sores  over 
sacrum. 

Cranium. — Antero-posterior  diameter  of  the  skull,  7f  inches;  trans- 
verse, 5-f  inches.  Shape  symmetrical,  but  rather  long  and  narrow; 
thickness  about  as  usual  in  the  colored  race.  On  the  external  surface 
of  the  right  temporal  bone  was  a  low,  flat  exostosis  of  irregular  shape. 
The  Pacchionian  depressions  were  large;  arterial  channels  normal. 

There  was  marked  enlargement  of  the  pituitary  fossa  and  the  cavity 
was  occupied  by  a  tumor,  which  was  removed  with  the  brain.  The 
antero-posterior  diameter  of  the  fossa  was  three-fourths  of  an  inch, 
the  transverse  1  inch,  and  the  depth  five-eighths  of  an  inch.  The 
walls  of  the  cavity  were  nearly  smooth,  but  showed  absorption  of  the 
bone  and  part  of  the  clinoid  processes.  The  dura  mater  was  not  abnor- 
mally adherent  to  the  bone  and  showed  nothing  unusual  except  dry- 
ness of  the  subdural  space,  and  the  convolutions  were  pressed  against 
its  inner  surface,  indicating  a  marked  degree  of  intracranial  tension. 

Brain:  Weight,  when  the  ventricles  were  emptied,  45  ounces 
(1,275.75  grams).  The  pial  veins  were  engorged;  membrane  in  other 
respects  as  usual.  At  the  base  a  soft  yellowish-white  mass  projected 
into  the  enlarged  pituitary  fossa.  The  tumor  mass  was  removed  with 
some  difficulty,  on  account  of  its  softness,  and  at  the  bottom  of  -the 
cavity  the  pituitary  body  was  found,  still  presenting  about  its  usual  size 
and  appearance.  The  infundibulum  was  still  distinguishable  and  con- 
nected the  pituitary  body  with  the  mass  above  it.     The  growth  had 


84  GOVERNMENT    HOSPITAL    FOR    THE    INSANE. 

forced  the  optic  nerve  and  chiasma  forward  and  spread  the  optic  tracts 
apart  at  their  anterior  extremities.  The  sheaths  of  the  nerves  and 
chiasma  were  firmly  adherent  to  the  capsule  of  the  tumor.  The  pos- 
terior portion  of  the  tumor,  the  arteries,  and  other  structures  at  the 
base  were  hidden  by  a  Large  subarachnoid  cyst,  which  extended  back- 
ward as  far  as  the  middle  of  the  pons  and  laterally  covered  over  the 
space  between  the  crura  and  the  tumor  in  front.  The  cyst  contained 
a  sanguinolent  fluid  and  a  quantity  of  crystalline  material  of  a  yellow- 
ish color,  which  was  found  to  be  cholesterin.  The  cavity  contained  in 
all  about  half  an  ounce  of  fluid  and  crystals.  The  cyst  was  carefully 
opened  and  washed,  to  expose  the  vessels  and  structures  beneath  it; 
it  was  then  found  that  the  cavity  communicated  with  a  broken-down 
ragged  cavity  in  the  tumor  mass.  The  cholesterin  was  probably  derived 
from  the  degenerated  tumor  tissue,  which  was  so  soft  as  to  be  readily 
washed  away  with  a  stream  of  water. 

The  arteries  on  the  left  side  were  found  to  be  adherent  to  the  capsule 
of  the  growth;  those  on  the  right  were  not  in  contact  with  it,  and  the 
cranial  nerves  were  not  involved,  except  the  optic  sheaths,  as  above 
described. 

"When  the  subarachnoid  c}rst  was  emptied  it  was  seen  that  the  floor 
of  the  third  ventricle  was  expanded  and  bulged  outward,  spreading  the 
crura  and  optic  tracts  apart  nearly  two  inches.  The  bulging  floor  of 
the  ventricle  seemed  to  be  entirely  distinct  from  the  overlying  sub- 
arachnoid cyst,  though  both  probably  had  some  relation  to  the  tumor 
not  clearly  explainable.  From  within  it  seemed  to  be  rnerery  an  exces- 
sive dilatation  of  that  portion  of  the  ventricular  cavity,  though  the 
lateral  ventricles  were  also  greatly  enlarged.  The  ependyma  was 
smooth;  veins  prominent;  no  cause  for.  the  excessive  accumulation  of 
fluid  was  discovered. 

Section  of  the  tumor  showed  a  soft,  degenerated  structure  through- 
out and  much  breaking  down  of  the  central  portions.  The  original 
size  of  the  growth  could  only  be  conjectured  by  the  size  of  the  fossa 
from  which  it  was  taken.  The  pituitary  body  was  normal  in  appear- 
ance to  the  naked  eye. 

The  convolutions  were  somewhat  flattened  against  the  dura  and  were 
slightly  atrophied.  The  cortex  seemed  thinner  than  normal  at  the 
summits  of  the  convolutions;  brain  substance  cedematous;  consistence 
reduced;  perivascular  spaces  enlarged,  and  tortuous  vessels  could  be 
seen  lying  within  them.  No  gross  lesions  were  revealed  by  section, 
and  the  cerebellum,  pons,  and  medulla  showed  nothing  but  the  general 
condition  of  the  brain  substance  above  noted.  Spinal  cord  seemed 
normal  so  far  as  examined. 

Thorax. — Pleural  cavities  normal.  Weight  of  left  lung,  15  ounces 
(425.25  grams);  right  lung,  22  ounces  (623.70  grams).  Anterior 
margins  emphysematous;  posterior  portions  engorged  and  slightly 
solidified  by  a  patchy  exudate. 

Heart:  Weight,  8f  ounces  (248.06  grams).  Pulmonary  valves  nor- 
mal; tricuspid  valve  admitted  four  fingers,  but  was  otherwise  normal. 
Aortic  valves  were  slightly  thickened  and  fenestrated  above  line 
of  contact;  mitral  valve  was  a  little  thickened  at  its  margins  and  had 
a  few  yellow  patches  at  its  base.  The  summits  of  the  muscular  papilla? 
were  fibrous;  endocardium  of  left  ventricle  opaque;  muscular  tissue 
relaxed  and  soft.     The  aorta  showed  some  atheroma  throughout. 

Abdomen. — Spleen  weighed  3  ounces  (85.05  grams);  capsule  wrinkled; 
pulp  dark  and  fibrous. 


GOVERNMENT    HOSPITAL    FOR    THE    INSANE.  85 

Kidneys:  Weight  of  left,  If  ounces  (134. 66  grams);  right,  4£  ounces 
(127.57  grams).  Capsule  of  left  thickened  and  adherent  to  the  cortex; 
surface  generally  smooth,  but  showed  some  small  depressions.  Capsule 
of  right  was  easily  removed,  and  the  organ  contained  more  blood  than 
the  left;  in  other  respects  they  were  the  same.  Urinary  bladder  was 
normal. 

Liver:  Weight,  21f  ounces  (701.00  grams).  Surface  smooth;  tissue 
showed  slight  passive  congestion.     Gall-bladder  normal. 

Stomach,  intestines,  and  other  abdominal  organs  appeared  normal. 

MICROSCOPICAL    EXAMINATION. 

Tumor:  The  tissue  of  the  growth  was  so  degenerated  that  its  nature 
could  not  be  determined.  The  capsule  consisted  of  fibrous  tissue,  but 
the  central  portions  were  composed  of  granular  fatt}T  debris  of  cells 
and  crystals  of  cholesterin.  The  total  degeneration  of  the  growth 
suggested  that  it  may  have  been  gummatous,  but  there  were  no  external 
or  internal  signs  of  syphilis  except  the  small  flat  thickening  on  the 
temporal  bone.  The  nature  of  the  growth  must  then  be  undetermined, 
but  that  it  originally  was  of  considerable  size  and  of  denser  consis- 
tence was  probable  from  the  enlargement  it  had  caused  in  the  pituitary 
fossa.  That  it  was  not  an  enlargement  of  the  pituitary  body  itself 
was  shown  b}T  the  presence  of  that  bod}T  in  nearly  its  normal  condition. 

The  brain  tissue  showed  the  effects  of  chronic  oedema  in  the  enlarge- 
ment of  the  perivascular  and  pericellular  spaces.  The  small  arteries 
were  frequently  tortuous,  and  blood  pigment  and  a  few  extra  cells  were 
found  in  the  surrounding  spaces.  The  nerve-cells  showed  various 
degrees  of  yellow  granular  degeneration.  The  cerebellum,  pons,  and 
medulla  were  not  examined.  The  spinal  cord  was  normal.  The  other 
organs  presented  nothing  of  interest  in  addition  to  the  naked-eye 
appearances. 

SEEIES  V.    SPECIFIC  GKANULOMATA. 

The  so-called  granulomata  have  been  uncommon  in  my  autopsies. 
As  has  already  been  mentioned,  no  sj^philitic  growth  of  any  size  has 
been  found  in  nearly  1,700  autopsies,  among  them  many  cases  of 
syphilitic  disease.  Specific  meningitis  has  been  found,  and  many  cases 
of  specific  arterial  disease,  but  cerebral  and  spinal  gummata  have 
been  conspicuously  absent,  even  when  tertiary  lesions  have  existed  in 
the  liver  and  elsewhere.  It  may  be  mentioned  in  this  connection  that 
the  later  tertiary  lesions  of  the  skin  and  bones  are  comparatively  rare 
among  our  patients,  a  fact  which  ma}^  be  attributed  to  the  more  or  less 
successful  treatment  of  the  disease  among  the  soldiers  and  sailors 
while  in  the  service. 

TUBERCULOMA   OF   BRAIN. 

But  one  case  of  tubercular  tumor  of  the  encephalon  has  come  under 
my  observation;  in  this  instance  multiple,  and  affecting  both  cerebrum 
and  cerebellum.  Tyson  places  tyroma  first  in  order  of  frequency; 
Bramwell  also  places  it  first  under  the  name  of  scrofulous  tumor.  It 
is  probable  that  the  statistics  upon  which  these  statements  were  based 
included  persons  of  all  ages,  as  tubercular  tumor  is  comparatively 
common  in  children,  but  rare  in  adults.     When  found  in  any  case  it 


86  GOVERNMENT    HOSPITAL    FOR   THE    INSANE. 

is  usually  secondary  to  tubercular  disease  of  the  lungs  or  elsewhere, 
as  it  was  in  this. 
Relatively  few  rases  of  tuberculosis  of  the  membranes  of  the  brain 

were  found  in  my  autopsies,  infection  of  the  central  nervous  organs 
being  for  sonic  reason  rare  in  adults.  In  the  case  described  there 
were  five  tumors  of  the  encephalon:  three  in  the  cerebrum,  two  in  the 
cerebellum.  They  were  all  of  moderate  size,  sharply  circumscribed, 
and  greatly  degenerated  in  the  interior.  Plate  XXVI  represents  the 
largest  of  the  growths  situated  in  the  cerebellum  near  the  vermis. 

The  growths  were  accompanied  by  tubercular  meningitis,  and  were 
secondary  to  tuberculosis  of  the  lungs,  lymphatic  glands,  vertebra?, 
and  other  organs. 

The  histological  features  of  these  tumors  were  not  characteristic 
nor  well  marked  on  account  of  degenerative  changes. 

The  more  rare  forms  of  granulomatous  growths  have  not  occurred 
in  my  autopsies. 

CASE    991. 

A   CASE    OF   EXTENSIVE    TUBERCULAR    DISEASE,    WITH    MULTIPLE    TUMOR 

OF   THE   BRAIN. 

B.  F.  B. ;  aged  19  years;  married;  laborer;  late  soldier;  nativity, 
United  States.  Mental  disease,  chronic  dementia;  duration,  four 
years.     The  following  clinical  history  was  furnished  b}r  Dr.  Foster: 

UB.  F.  B.  was  admitted  September  3, 1892,  from  the  Soldiers'  Home. 
The  records  of  the  Home  show  that  he  was  characterized  on  his  admis- 
sion there  by  'imbecility'  and  a  'shuffling  gait,'  and  that  the  patellar 
reflex  was  exaggerated.  These  symptoms,  with  bronchial  respiration 
at  the  apex  of  right  lung,  were  the  only  symptoms  recorded  prior 
to  his  admission  to  the  Toner  Building,  in  October,  1894.  He  then 
showed  posterior  angular  projection  of  the  second  and  third  lumbar 
spinous  processes  and  in  the  region  of  the  tenth  dorsal  vertebra. 
There  was  tenderness  of  the  entire  dorsal  and  lumbar  spine.  He  was 
suffering  from  pain  in  the  lower  extremities,  and  the  latter  presented 
marked  muscular  weakness,  with  diminished  tactile  sensibility.  The 
pain  in  the  legs  was  not  constant,  but,  relieved  by  rest  and  counter- 
irritation  along  the  spine,  recurred  paroxysmally.  He  had  occasional 
attacks  of  vomiting,  with  moderate  rise  of  temperature  and  pulse. 

"Weakness  and  discomfort  in  moving  compelled  him  to  keep  his 
bed  during  the  last  six  months.  Tuberculosis,  which  had  been  latent 
in  the  apex  of  the  right  lung,  developed,  affecting  lungs,  intestines, 
liver,  kidneys,  and  brain;  but  without  cough  or  expectoration.  Dur- 
ing the  greater  part  of  the  time  he  expressed  himself  as  comfortable, 
notwithstanding  the  severe  spinal  caries. 

"The  mental  symptoms  were  simply  those  of  intellectual  weakness. 
He  was  able  to  manifest  an  interest  in  his  diet,  calling  for  such  food 
as  he  fancied.  He  would  occasionally  speak  of  pain  in  his  legs  when 
questioned,  but  seemed  to  have  a  singular  immunity  from  suffering 
until  the  last  ten  days  of  life. 

"The  pupils  presented  no  abnormality,  and  there  was  no  ocular, 
facial,  or  bulbar  paralysis.  He  never  complained  of  headache,  and  did 
not  speak  of  giddiness.  There  was  much  apparent  suffering  during  the 
last  week  of  life,  but  hebetude  appeared,  deepening  into  stupor,  and 
he  was  most  of  the  time  unconscious  of  his  surroundings. 


GOVERNMENT    HOSPITAL    FOR    THE    INSANE.  87 

"The  usual  symptoms  of  brain  tumor  (except  the  vomiting,  which 
was  attributed  to  the  spinal  lesion)  were  all  conspicuously  absent.  He 
had  no  hallucinations,  delusions,  or  delirium.  Dementia  progressed 
noticeably  during-  the  last  two  or  three  months." 

Autopsy  four  hours  after  death.  Body  emaciated;  rigor  mortis 
slight;  tattooed  designs  on  right  forearm.  Marked  angular  projection 
of  the  spinous  processes  of  the  second  and  third  lumbar,  and  the  ninth 
and  tenth  dorsal,  vertebrae;  some  deformity  of  lower  cervical  and 
upper  dorsal  region,  the  first  dorsal  process  being  turned  toward  the 
left.  Bedsores  had  formed  over  the  dorsal  and  lumbar  spinal  pro- 
jections. 

Omnium.—  Antero-posterior  diameter,  7i  inches;  transverse,  5& 
inches.  The  skull  was  very  thick  and  dense,  especially  in  the  frontal 
and  occipital  regions.  In  the  thickest  place  in  the  frontal  bone  it 
measured  one-half  inch;  in  the  occipital  region,  three-fourths  of  an 
inch;  in  the  temporal,  three-eighths  of  an  inch.  The  sutures  were 
indistinct  in  the  inner  table,  but  visible  externally;  diploe  scanty, 
especially  in  the  regions  of  greatest  density  and  thickness;  shape 
fairly  symmetrical;  arterial  depressions  well  marked.  Dura  mater 
not  unusually  adherent  to  the  bone,  but  there  were  slight  adhesions 
to  the  cerebellar  pia  mater  over  one  of  the  tumors  and  to  the  pia  over 
a  small  growth  in  the  right  occipital  lobe.  There  were  no  indica- 
tions of  increased  intracranial  tension,  and  the  cerebro-spinal  fluid  was 
excessive  in  quantity. 

Brain:  Weight  of  right  hemisphere,  15|  ounces  (439.42  grams);  left, 
16  ounces  (453.60  grams);  cerebellum,  pons,  and  medulla,  5i  ounces 
(155.92  grams).  The  pia  mater  over  the  convexity  was  thickened, 
opaque,  its  meshes  filled  with  serum,  and  the  pial  vessels  were  very 
tortuous.  At  the  posterior  extremity  of  the  median  surface  of  the 
right  occipital  lobe  the  pia  was  adherent  to  the  falx  major  over  a  small 
area,  corresponding  with  a  flat  irregular  tubercular  growth  in  the  cor- 
tex. In  the  right  cerebellar  fossa  the  pia  was  adherent  to  the  dura 
mater  over  a  tumor  mass  hereafter  to  be  described.  At  the  base  in 
the  vicinity  of  the  optic  chiasma,  tuber  cinereum,  crura,  pons,  and 
Sylvian  fissures,  the  pia  mater  and  arachnoid  were  thickened  and  mat- 
ted together,  and  the  vessels  were  studded  with  small  whitish  nodules, 
which  were  found  to  be  miliary  tubercles.  The  convolutions  were 
greatly  shrunken  over  the  convexity  and  median  surfaces;  ventricles 
moderately  enlarged.  In  the  right  ventricle  a  tumor,  about  one- 
fourth  of  an  inch  in  diameter,  was  found  in  the  head  of  the  caudate 
nucleus,  projecting  slightly  into  the  cavity.  It  was  hard,  greenish- 
yellow  in  color,  indistinctly  concentrically  striated,  and  sharply  cir- 
cumscribed from  the  surrounding  tissue.  The  section  projected 
slightly  from  the  soft  brain  substance  around  it,  but  the  tumor  could 
not  be  enucleated  without  tearing  the  brain  tissue.  On  the  left  side  a 
tumor  of  similar  appearance,  but  about  three-fourths  of  an  inch  in 
diameter,  was  found  in  the  median  surface  of  the  frontal  lobe,  just 
anterior  to  the  white  commissure  and  below  the  genu  of  the  corpus 
callosum.  Section  showed  that  the  growth- was  apparently  below  the 
cortex,  and  that  it  had  encroached  upon  the  caudate  and  lenticular 
nuclei  and  the  anterior  extremity  of  the  internal  capsule.  The  small 
growth  in  the  right  occipital  lobe,  before  mentioned,  presented  the 
same  general  appearances  and  was  supposed  to  be  of  the  same  nature. 
The  brain  tissue  was  very  pale,  soft,  and  (edematous;  perivascular 
spaces  large. 


88  GOVERNMENT    HOSPITAL    FOR    THE    INSANE. 

In  the  right  hemisphere  of  the  cerebellum  were  two  tumors  similar 
in  appearance  to  those  found  in  the  cerebrum.  One  was  situated  at 
the  outer  portion  of  the  posterior  border  of  the  hemisphere  just  above 
the  great  horizontal  fissure;  the  other  was  in  the  superior  portion,  near  its 
junction  with  the  middle  lobe;  each  was  about  half  an  inch  in  diameter 
and  nearly  globular.  The  tumors  appeared  to  be  beneath  the  general 
cortical  surface  of  the  organ  and  to  have  pressed  aside  and  taken  the 
place  of  the  nervous  substance.  They  probably  originated  from  some 
portion  of  the  pia  mater  between  the  folia,  and  grew  in  every  direction. 
The  outer  one  had  reached  the  surface  and  became  adherent  to  pia  and 
dura  mater;  the  other  had  a  thin  layer  of  cortex  over  its  most  project- 
ing portion.  Section  of  the  left  hemisphere,  pons,  medulla,  and  upper 
cervical  spinal  cord  revealed  nothing  of  importance  in  addition  to  the 
general  condition  of  the  brain  substance  above  noted. 

Thorax. — Firm  pleuritic  adhesions  on  both  sides;  right  pleural  cavity 
entirely  obliterated.  Weight  of  right  lung,  38  ounces  (1,117.30  grams); 
left  lung,  281  ounces  (807. 97  grams);  both  were  completely  tilled  with 
tubercular  nodules. 

Heart:  Weight,  9f  ounces  (270.41  grams).  Slight  increase  of  peri- 
cardial fluid.  Pulmonary  valves  normal;  tricuspid  valve  normal. 
Aortic  valves  showed  a  little  chronic  thickening  along  line  of  contact; 
mitral  valve  a  little  thickened  at  its  margins. 

Abdomen. — Spleen:  Weight,  12£  ounces  (351.37  grams);  capsule 
slightly  wrinkled;  pulp  firm  and  rather  pale.  When  tested  with  iodine 
it  did  not  show  the  reaction  for  amyloid  material,  and  no  tubercles 
were  visible  to  the  naked  eye. 

Kidneys:  Weight  of  left,  7i  ounces  (205.53  grams);  right,  b\  ounces 
(155.92  grams).  The  pelves  were  dilated  and  the  left  contained  a 
deposit  of  thick  pus  from  an  abscess  which  communicated  with  it;  a 
number  of  smaller  deposits  of  pus  were  scattered  throughout  the  organ. 
The  right  kidney  was  less  affected,  but  numerous  foci  of  purulent 
inflammation  were  found  scattered  everywhere  through  it.  The  cap- 
sules were  slightly  adherent;  surfaces  smooth  except  where  the  small 
abscesses  were  situated  in  the  cortex.  The  lesions  presented  the  char- 
acteristics of  tubercular  inflammation.  The  urinary  bladder  was 
dilated  and  the  walls  were  hypertrophied. 

Liver:  Weight,  63  ounces  (1,786.05  grams).  The  right  lobe  was 
marked  by  the  ribs.  The  tissue  presented  a  marked  nutmeg  appear- 
ance, probabl}T  due  to  passive  congestion  and  fatty  infiltration.  Man3T 
small  whitish  nodules,  supposed  to  be  miliary  tubercles,  were  found 
scattered  through  the  tissue.     The  gall-bladder  was  normal. 

Intestines:.  A  moderate-sized  ulcer  was  found  in  the  ileum  near  the 
ileo-ca?cal  valve,  and  the  edge  of  the  valve  was  ulcerated.  There 
were  some  large  ulcers  in  the  head  of  the  colon,  one  very  large  and 
deep  about  1  inches  from  the  caput  coli,  and  one  3  inches  beyond  the 
last.  The  vermiform  appendix  wTas  ulcerated  for  about  two-thirds  of 
its  length  from  the  extremity  and  filled  with  pus. 

The  stomach  appeared  normal.  Other  abdominal  organs  presented 
no  signs  of  disease. 

Spinal  column:  When  the  spinal  canal  was  exposed,  marked  curva- 
ture was  observed  in  the  dorsal  and  lumbar  regions,  where  the  spi- 
nous processes  were  prominent.  These  regions  were  found  to  corre- 
spond with  extensive  caries  of  the  bodies  of  the  vertebra?.  In  the 
lumbar  region  the  bodies  of  the  second  and  third  lumbar  vertebra? 


GOVERNMENT    HOSPITAL    FOR   THE    INSANE.  89 

were  nearty  destroyed,  and  large  masses  of  necrotic  bone  were  com- 
pletely separated  and  lay  with  the  thick  pus  deposits  in  the  place  of 
the  vertebrae.  In  the  dorsal  region  the  spinal  dura  mater  was  thick- 
ened, adherent  to  the  bone,  and  over  its  inner  surface  was  a  hemor- 
rhagic false  membrane.  A  small  hemorrhage,  outside  of  the  spinal 
dura  mater,  was  found  over  the  site  of  the  greatest  dorsal  curvature. 
From  the  posterior  view  of  the  spinal  column  it  appeared  that  the 
carious  region  was  about  3  inches  in  length  in  the  dorsal  region  and  4 
inches  in  the  lumbar,  but  examination  from  the  front  revealed  that 
the  caries  extended  from  the  seventh  dorsal  vertebra  to  the  sacrum 
and  actual^  involved  the  upper  portion  of  the  sacrum  and  adjoining 
portions  of  the  iliac  bones.  The  carious  regions  in  front  were  all  con- 
tinuous with  each  other,  and  large  pus  deposits,  some  liquid,  some 
caseous,  lay  all  along  the  track  of  the  disease.  The  psoas  and  iliacus 
intern  us  muscles  of  both  sides  were  infiltrated  with  large  pus  accumu- 
lations, and  that  on  the  right  side  was  almost  ready  to  point  in  the 
groin,  having  reached  Poupart's  ligament.  After  removal  of  the 
overlying  tissues  it  was  found  that  many  of  the  bodies  of  the  vertebrae 
were  extensively  eroded,  and  that  the  body  of  the  second  lumbar  was 
almost  destroyed. 

Examination  of  the  spinal  cord  itself  was  not  conclusive  without 
the  aid  of  the  microscope,  but  it  appeared  softer  in  the  regions  of  the 
greatest  caries,  and  the  membranes  were  thickened  and  adherent  to 
the  spinal  canal  in  the  dorsal  region. 

MICROSCOPICAL   EXAMINATION. 

The  tumors  of  the  brain  presented  the  usual  characteristics  of  tuber- 
cular tumor.  These  growths  are  essentially  masses  of  tubercular  tis- 
sue produced  by  the  development  and  coalescence  of  vast  numbers  of 
miliaiy  granulations  which  have  their  origin  in  the  vessel  walls.  These 
miliary  tubercles  have  the  same  essential  structure  wherever  found, 
being  composed  of  lymphoid  cells,  epithelioid  cells,  an  imperfect  inter- 
cellular reticulum,  and  giant  cells,  the  last  two  constituents  not  being 
essential  to  the  simplest  form  of  miliary  tubercular  granulation. 

In  the  formation  of  these  tumor  masses  the  miliary  granulations 
coalesce;  the  original  vessels  are  soon  obliterated  by  destruction  of 
their  walls  and  thrombosis,  and  the  new  granulation  vessels,  if  formed, 
rapidly  disappear,  so  that  the  mass  soon  degenerates  in  its  central  por- 
tions. Surrounding  the  degenerated  portion  is  a  zone  of  more  recent 
granulation  tissue,  which  by  continuous  growth  adds  to  the  periphery 
of  the  mass,  which  thus  extends  in  eveiy  direction  from  the  center  and 
to  the  naked  eye  presents  a  concentrically  striated  appearance. 

In  the  central  portions  of  the  present  tumors  scarcely  a  trace  of 
the  original  cellular  structure  could  be  distinguished.  Around  the 
periphery  the  cell  structure  became  more  evident,  and  some  traces  of 
tubercular  granulations  could  be  seen.  In  the  sections  examined  no 
giant  cells  were  discovered.  A  few  vessels  were  found  in  the  periph- 
eiy  of  the  tumors  still  filled  with  blood.  In  the  granulation  zone 
the  vessels  showed  great  accumulations  of  cells  around  their  walls,  and 
this  infiltration  was  observed  to  extend  along  the  vessel  walls  for  some 
distance  into  the  brain  substance.  Portions  of  the  pia  mater  adjacent 
to  the  tumors  were  infiltrated  with  round  cells,  especially  in  the  vicinity 
of  the  vessels. 


90  GOVERNMENT    HOSPITAL    FOR    THE    INSANE. 

The  brain  substance  generally  showed  widened  perivascular  and 
pericellular  spares  and  some  pigmentary  and  granular  degeneration 
of  the  nerve  cells.     In  the  walls  of  the  pial  vessels  at  the  base,  and  in 

many  of  the  small  cortical  vessels  in  the  same  region,  many  tubercular 
granulations  were  found. 

The  tissue  of  the  cerebellum  showed  nothing  of  interest,  except  in 
the  vicinity  of  the  tumors,  as  above  noted. 

The  spinal  cord  has  not  yet  l>een  examined. 

The  other  organs  showed  tubercular  disease  in  all  cases  where  the 
nodules  and  lesions  were  found  with  the  naked  eye.  The  hones  were 
not  examined,  hut  the  tubercular  nature  of  the  caries  seemed  self- 
evident. 

SERIES  VI.    ANEUEISMS. 

CASE  805. 

ANEURISM  OF  THE  RIGHT  MIDDLE  CEREBRAL  ARTERY  AND  OF  THE 

ABDOMINAL  AORTA. 

T.  S.  C. ;  aged  61;  widower;  late  soldier;  nativity,  United  States; 
mental  disease,  chronic  epileptic  mania.  This  patient  had  convulsive 
attacks  occasionally,  which  were  believed  to  be  epileptic;  he  was  some- 
what demented;  was  feeble,  and  kept  in  bed,  but  snowed  no  distinct 
paralysis  except  ptosis  of  right  eyelid.  He  had  occasional  attacks  of 
vomiting,  and  a  few  days  before  he  died  the  vomitus  contained  blood. 
The  eyes  were  not  examined  with  the  ophthalmoscope,  but  sight  was 
impaired.  The  duration  of  his  mental  trouble  was  over  eighteen  3Tears. 
Death  occurred  in  a  convulsion,  preceded  by  great  prostration  from 
hemorrhage. 

Autopsy  thirty  hours  after  death.  Bod}7  fairly  well  nourished; 
marked  pallor  of  skin. 

Cranium. — Antero-posterior  diameter,  7i  inches;  transverse,  of 
inches.  Skull  a  little  thicker  than  usual,  and  a  few  small  exostoses 
were  found  on  the  inner  surface  of  the  frontal  bone.  The  sutures  were 
partly  obliterated  and  the  bone  was  dense.  The  right  posterior  clinoid 
process  and  a  small  portion  of  the  adjoining  dura  were  adherent  to  a 
tumor  mass  in  the  brain  and  were  brought  away  with  it. 

Brain:  Weight  of  right  half,  20f  ounces  (588.26  grams);  left  half, 
20i  ounces  (581.17  grams).  Pia  mater  cedematous;  veins  moderately 
full  of  blood;  arteries  at  the  base  atheromatous  in  patches,  especially 
the  vertebrals.  Convolutions  were  moderately  atrophied  over  the 
whole  brain;  no  effects  of  pressure  could  be  distinguished. 

On  the  right  side  at  the  base  a  tumor  mass  was  situated  on  the  inner 
side  of  the  uncinate  gyrus  and  extended  from  the  anterior  border  of  the 
pons  to  the  posterior  border  of  the  orbital  convolutions.  The  tumor 
was  about  1\  inches  in  its  longest  diameter;  it  was  globular  in  shape 
and  of  firm  consistence.  The  anterior  extremity  of  the  temporal  lobe 
was  pressed  outward,  the  cms  pressed  upon  and  indented  slightly,  the 
middle  cerebral  artery  was  displaced  forward,  the  posterior  communi- 
cating artery  was  pressed  inward,  and  the  third  nerve  was  displaced 
and  stretched  over  the  tumor.  The  anterior  extremity  of  the  ten- 
torium was  adherent  to  the  capsule  of  the  growth,  and  the  two  adhered 
firmly  to  the  posterior  clinoid  process.  The  capsule  of  the  tumor  was 
calcareous  and  thick,  and  the  accommodation  of  the  parts  around  to  it 
showed  the  growth  to  be  of  long  standing. 


GOVERNMENT    HOSPITAL    FOR   THE    INSANE.  91 

Section  revealed  the  true  T!haracter  of  the  tumor;  it  proved  to  be  tin 
aneurism  which  had  formed  on  the  middle  cerebral  artery  at  a  point 
between  the  posterior  communicating  and  the  anterior  choroid  artery. 
The  opening-  into  the  vessel  was  shown  to  be  about  one-sixteenth  of  an 
inch  in  diameter,  and  some  blood  still  entered  the  aneurismal  sac, 
though  the  cavity  was  nearly  filled  by  dry,  friable  laminated  clot. 
(The  photograph  shows  the  opening  into  the  vessel  and  the  appearance 
of  the  aneurismal  contents.) 

The  brain  tissue  was  very  soft  in  the  vicinity  of  the  tumor,  so  that 
it  was  difficult  to  section  it  without  displacement.  The  thalamus  was 
encroached  upon  by  the  sac  and  pressed  upward;  the  lenticular  nucleus 
and  the  anterior  portion  of  the  internal  capsule  were  pressed  upward. 
The  optic  tract  was  almost  completely  destroyed  at  its  posterior  por- 
tion. The  situation  of  the  tumor  was  such  that  the  main  fibers  of  the 
internal,  capsule  passed  over  and  behind  it,  and  the  pressure  upon  the 
crus  was  slight;  the  absence  of  distinct  paralysis  is  thus  explained. 
The  slow  growth  of  the  aneurism  and  its  gradual  cure  by  obliteration 
of  the  sac  probably  account  for  the  absence  of  more  definite  symptoms. 
The  brain  tissue  in  general  was  reduced  in  consistence  and  cedematous, 
but  there  were  no  gross  lesions  elsewhere  in  the  brain. 

Tliorax. — Firm  pleuritic  adhesions  on  both  sides.  Lungs:  Weight  of 
right,  21f  ounces  (616.61  grams);  left,  15  ounces  (425.25  grams).  The 
left  lung  showed  some  hypostasis  posteriorly  and  some  chronic  scar- 
like nodules  at  the  apex,  possibly  the  remains  of  an  arrested  tubercu- 
losis. On  the  right  side,  occupying  the  position  of  the  lower  lobe, 
was  a  large  cyst-like  cavity  between  the  two  layers  of  the  pleura  which 
had  a  capacity  of  nearly  2  pints.  The  cyst  walls  were  about  one-eighth 
of  an  inch  in  thickness,  and  were  composed  of  tough,  fibrous  tissue. 
The  contents  of  the  cyst  were  yellowish  serum,  and  shreddy,  caseous 
material  floating  in  the  serum  and  adherent  to  the  walls.  The  lower 
lobe  of  the  lung  was  pressed  upward  and  backward  by  the  c}^st,  and  a 
portion  of  the  tissue  may  have  been  destroyed.  The  parietal  pleura 
and  the  diaphragm  were  adherent  to  the  cyst  wall  and  had  to  be 
removed  with  it.  The  lung  was  not  sectioned,  but  nothing  abnormal 
could  be  found  in  the  remaining  portions. 

Heart:  Weight,  10^  ounces  (297.67  grams).  Valves  of  right  side, 
normal;  aortic  valves  thickened,  calcareous,  and  all  the  contiguous 
edges  of  the  segments  were  adherent  so  that  the  orifice  was  much  nar- 
rowed; the  aorta  showed  some  atheroma;  the  mitral  valve  was  slightly 
thickened  at  its  margins;  summits  of  the  muscular  papilla?  fibrous. 

Abdomen. — Spleen:  Weight,  4  ounces  (113.40  grams);  capsule  wrin- 
kled; pulp  pale  and  fibrous;  splenic  artery  very  calcareous. 

Kidneys:  Weight  of  left,  3i  ounces  (99.22  grams);  right,  2i  ounces 
(63.78  grams).  The  pelvis  of  the  left  contained  several  fragments  of 
calculi,  which  may  have  originally  been  one  large  calculus  broken  in 
removal  of  the  organ.  The  capsules  adhered  slightly;  surfaces  gran- 
ular; cortical  substance  extreme^  thin;  several  large  cysts  in  each; 
pelvic  fat  increased;  pyramids  atrophied.  The  calices  of  the  left  kid- 
ney, its  ureter,  and  the  urinary  bladder  contained  some  gritty  calcare- 
ous material  and  a  little  muco-pus. 

Examination  of  the  abdominal  aorta  revealed  a  small  aneurism,  about 
\\  inches  in  diameter,  which  had  formed  on  the  vessel  at  the  point  where 
it  is  crossed  by  the  duodenum.  Adhesive  inflammation  had  united  the 
sac  to  the  intestine,  and  rupture  had  occurred  into  the  bowel.    A  coag- 


92  GOVERNMENT    HOSPITAL    FOR    THE    INSANE. 

ulum  lnul  formed  in  the  interior  of  the  infest  inc.  which  extended  nearly 
the  whole  length  of  the  snnfll  intestine  from  the  point  of  perforation 
to  the  ileo-csecal  valve. 

Other  abdominal  organs  normal  to  the  naked  eye. 

MICROSCOPICAL    EXAMINATION. 

Examination  of  the  contents  of  the  aneurism  was  not  considered 
necessary.  The  brain-cells  showed  marked  degenerative  changes; 
some  of  the  vessels  were  tortuous,  and  pigment  was  scattered  along 
their  walls. 

The  kidneys  showed  advanced  interstitial  nephritis. 

Other  organs  not  examined. 

Note. — Though  aneurism  can  not  be  properly  considered  as  a  tumor  of  the  brain, 
the  symptoms  may  be  similar  and  the  results  the  same.  The  subject  of  intracranial 
aneurism  is  treated  with  tumors  of  the  brain  by  Bramwell  and  others,  and  the  close 
association  with  the  true  neoplasmata  clinically  will  perhaps  warrant  the  introduc- 
tion of  this  case  here. 


SEEIES  VII    OSTEOMATA. 

Osteomata  of  the  skull  ma}'  penetrate  the  brain  mechanically  and 
interfere  with  its  function,  but  such  growths  are  usually  small  and 
flat  and  give  no  ante-mortem  evidence  of  their  presence.  Osseous 
growths  of  this  character  have  been  quite  common  in  my  autopsies, 
but  owing  to  the  uncertainty  as  to  their  aetiology  they  have  not  been 
placed  with  the  true  neoplasmata.  Occasionally  we  meet  with  exten- 
sive nodular  hyperostoses  covering  the  inner  surface  of  the  skull 
bones,  usuall}7  the  frontal,  such  as  shown  in  PI.  XXIX.  As  the  exact 
relation  of  these  growths  to  brain  atroph}^  to  inflammation,  and  to 
developmental  defects  is  not  }Tet  settled,  they  probably  should  not  be 
considered  as  tumors.  Though  they  are  usuall}'  associated  with 
extreme  dementia  and  often  with  imbecility,  the  exact  relation  to  the 
mental  defect  is  hard  to  determine.  The  bone  thickening  has  been 
regarded  as  compensatory  to  atrophry  of  the  brain,  but  the  condition 
is  comparatively  rare,  while  brain  shrinkage  is  extremely  common. 
It  seems  more  probable  that  the  process  is  set  up  during  the  period  of 
development  and  that  as  a  consequence  normal  cranial  and  cerebral 
growth  does  not  occur.  The  dura  mater  is  always  adherent,  thinned, 
and  deficient  over  the  roughened  surface. 

More  common,  but  probably  of  less  importance,  are  the  small 
irregular  flat  masses  of  bone  found  usually  in  the  falx.  Though  their 
aetiology  is  unsettled,  they  are  probably  errors  of  development  and 
may  be  classed  with  tumors.  Inflammation  has  been  suggested  as  a 
cause,  though  this  is  hard  to  demonstrate.  They  are  usually  thin  and 
flat,  but  are  sometimes  thick  enough  to  make  slight  impressions  in  the 
adjoining  surfaces  of  the  brain.  The  dura  over  the  mass  is  thin  and 
defective,  leaving  small  bone  surfaces  bare,  and  it  is  usually  easy 
to  enucleate  the  osseous  growth.  Signs  of  inflammation  are  usually 
wanting  and  they  are  not  associated  with  any  special  form  of  mental 
disease.  PL  XXX  shows  a  group  of  these  growths  from  a  number 
of  cases,  photographed  the  natural  size. 


GOVERNMENT    HOSPITAL    FOR   THE    INSANE.  93 

MULTIPLE  TUMORS. 

In  several  instances  tumors  of  different  character  coexisted  with 
the  intracranial  growths.  These  may  be  regarded  as  merely  coin- 
cidences, as  the  growths  were  usually  widely  different  in  structure 
and  situation,  but  as  interesting  associated  conditions  they  may  be 
here  mentioned. 

In  case  853  there  were  several  small  wart-like  growths  on  the  dura 
and  falx,  besides  the  large  tumor  within  the  brain.  These,  however, 
were  regarded  as  of  the  same  origin  as  the  cerebral  growth,  though 
the  relationship  was  hard  to  demonstrate. 

In  case  1436  a  small  osteoma  of  the  falx  coexisted  with  a  large  dural 
endothelioma;  in  case  1146  a  large  soft  cancer  of  the  stomach  with  an 
endothelial  sarcoma  of  the  dura  mater.  A  small  papuliferous  cyst 
adenoma  was  found  in  the  kidney  in  case  1516,  the  intracranial  growth 
being  a  small  spindle-celled  endothelial  sarcoma.  In  case  1582  a  dural 
endothelial  growth  was  associated  with  a  bulky  hematoma,  which 
would  have  complicated  the  diagnosis  had  tumor  been  suspected. 

A  medium-sized  hemorrhagic  spindle-celled  sarcoma  of  the  cerebel- 
lum found  in  case  1130  was  associated  with  numerous  soft  fibromata 
of  the  skin.  A  possible  relationship  might  be  claimed  in  this  instance, 
though  microscopic  examination  failed  to  show  any  positive  evidence 
of  origin  from  the  peripheral  nerves. 

In  case  833  three  tumors  of  widely  different  structure  and  situation, 
with  evidently  no  setiological  relationship,  were  found  at  the  autopsy. 
The  intracranial  growth  was  a  small  dural  endothelioma,  and  the  asso- 
ciated tumors  were  an  adenoid  cancer  of  the  stomach  and  a  round- 
celled  sarcoma  of  the  testicle  with  secondary  deposits  in  other  organs. 

In  case  1619  a  cavernous  angioma  of  the  liver  coexisted  with  glioma 
of  the  brain,  and  in  case  788  a  tumor  of  the  hypophysis  was  found  in 
an  aged  colored  woman  who  had  a  number  of  uterine  fibro-myomata. 
The  degenerated  tumor  of  the  pituitary  fossa,  found  in  case  961,  was 
associated  with  a  large  flat  exostosis  of  the  outer  surface  of  the  right 
temporal  bone  and  moderate  scaphoid  deformity  of  the  skull. 

The  tubercular  tumors  in  case  991  were  multiple,  and  in  case  805  a 
large  aneurism  of  a  cerebral  artery  coexisted  with  a  small  one  of  the 
abdominal  aorta  which  ruptured  into  the  duodenum  and  caused  death. 

It  will  be  observed  that  the  more  rare  and  less  important  intracranial 
tumors  are  not  represented  in  the  writer's  collection.  Psammo-sar- 
coma,  and  psammoma,  tumors  of  doubtful  character,  are  probably  in 
many  instances  spindle-celled  endothelial  sarcomata  with  calcified  and 
hyaline  cell-spherules.  Man}r  tumors  described  as  fibromata  and  fibro- 
sarcoma may  probabty  be  placed  with  the  same  class,  as  may  certainly 
be  many  of  those  commonly  called  endothelioma. 

The  more  uncommon  forms  of  sarcoma,  such  as  alveolar,  melanotic, 
and  perithelial  types  have  not  been  met  with  in  my  autopsies. 

Angioma  has  been  reported  as  occurring  in  the  brain,  though  care 
must  be  taken  not  to  confuse  this  growth  with  telangiectasia  of  certain 
parts  of  gliomata  and  other  tumors.  Lipoma  and  chondroma  have 
been  found  within  the  cranium,  but  must  be  exceedingly  rare. 

Primary  carcinoma  of  the  brain  would  of  course  be  possible  and  sec- 
ondary deposits  may  occur,  though  none  have  been  found  in  the  many 
cases  of  carcinoma  of  other  organs  examined  by  the  writer. 


94  GOVERNMENT    HOSPITAL    FOR   THE    INSANE. 

With  the  exception  of  some  large  subarachnoid  accumulations  of 
fluid,  no  primary  cerebral  cysts  have  come  under  my  observation. 

The  foregoing  collection  comprises  all  of  the  cases  of  intracranial 
growth  in  the  2,80?  deaths  which  occurred  in  this  hospital  during  the 
fast  eighteen  years.  Of  the  total  number  of  cases  1,(342  were  exam- 
ined, and,  so  far  as  could  be  determined  clinically,  ail  cases  of  intra- 
cranial tumor  were  included.  When  we  recall  that  several  of  the 
tumors  were. small  and  so  situated  that  they  could  have  had  no  etio- 
logical relation  to  the  mental  disease,  the  comparative  infrequency  of 
intracranial  tumor  as  a  cause  of  insanity  becomes  apparent. 


INDEX  TO  CASES. 


Page. 

Case  853. — Spindle-celled  endothelial  sarcoma  of  brain,  with  multiple  dural 

nodules 19 

Case  842. — Spindle-celled  endothelial  sarcoma 22 

Case  774. — Spindle-celled  endothelial  sarcoma 25 

Case  1436. — Spindle-celled  endothelial  sarcoma  of  dura,  with  small  osteoma  of 

falx 27 

Case  76. — Spindle-celled  endothelial  sarcoma  penetrating  the  brain 29 

Case  715. — Spindle-celled  endothelial  sarcoma  of  the  falx 30 

Case  1146. — Spindle-celled  endothelial  sarcoma  of  dura  and  soft  carcinoma  of 

stomach 32 

Case  1516. — Spindle-celled  endothelial  sarcoma  of  dura,  with  small  cyst- 
adenoma  of  kidney 36 

Case  965. — Spindle-celled  endothelial  sarcoma,  with  degenerated  cell  spherules.  37 

Case  1503. — Spindle-celled  endothelial  sarcoma  of  dura 40 

Case  1582. — Spindle-celled  endothelial  sarcoma  of  dura  mater,  with  hematoma.  42 

Case  1178. — Spindle-celled  endothelial  sarcoma 44 

Case  789. — Spindle-celled  endothelial  sarcoma 47 

Case  1130. — Hemorrhagic  spindle  sarcoma  of  the  cerebellum,  with  multiple 

soft  fibromata  of  the  skin •_ 49 

Case  833. — Endothelial  spindle-celled  sarcoma  of  the  dura  mater,  with  adenoid 

cancer  of  the  stomach  and  round-celled  sarcoma  of  the  testicle 53 

Case  539. — Endothelial  sarcoma  of  dura  mater 56 

Case  278. — Spindle-celled  endothelial  sarcoma  of  the  dura  mater 59 

Case  601. — Glioma  of  the  brain 61 

Case  832. — Glioma  of  the  brain 62 

Case  1053. — Glioma  of  the  brain 65 

Case  1426. — Glioma  of  the  brain 67 

Case  1619. — Glioma  of  the  brain  and  cavernous  angioma  of  the  liver 69 

Case  820. — Glioma  or  glio-sarcoma  of  the  brain 72 

Case  1237. — Small  round-celled  sarcoma  of  the  brain 74 

Case  788. — Adenoma  of  the  hypophysis  and  uterine  leiomyomata 77 

Case  870.  —Adenoma  of  the  hypophysis 80 

Case  964. — Tumor  of  pituitary  fossa  and  large  cranial  exostosis 83 

Case  991. — Tubercular  tumors  of  brain 86 

Case  805. — A  neurism  of  cerebral  artery  and  of  the  abdominal  artery 90 

Case  1246. — Plate  XXIX,  showing  hyperostoses  of  frontal  bone  and  scaphoid 

deformity  of  skull.     Description , 9, 92 

Plate  XXX,  showing  a  number  of  small  osteomata  of  the  falx  from  various 

cases.     Description 92 

95 

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